CLM-2026-011213
Desert Medical Group, Internal Medicine. Service 2026-04-01 to 2026-04-04 at inpatient hospital (POS 21). Received 2026-05-16.
Member
Resolved through the identity graph
- Member
- Larry Mendoza
- Member ID
- UHC-94891-67
- Date of birth
- 1972-11-08
- Identity
- Verified6 records, confidence 0.94
- Claim record
- CLMCLM-416000
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2204
- Coverage period
- 2024-10-01 to present
- Deductible
- $359.71 of $500.0072%
- Out-of-pocket maximum
- $464.04 of $1,000.0046%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3427053921
- Network
- In network
- Rendering NPI
- 1258204878
- Location
- San Diego, CA · TIN 22-6599572
- Authorisation / referral
- none / REF418433
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $258.00 | $141.90 | $140.45 | $1.45 | Paid |
| Totals | $258.00 | $141.90 | $140.45 | $1.45 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-760919
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-04-01 to 2026-04-03
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003690 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-04-01: NAVIGATE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Medical Group (3427053921). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Medical Group2026-04-04 10:10
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-760919.pdf2 pages
Itemised statement totalling $258.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028421 | 2026-09-06 | Desert Imaging Center | $141.00 | Approved |
| CLM-2026-019076 | 2026-04-26 | Northgate Cardiovascular Associates | $7,991.00 | Approved |
| CLM-2026-024124 | 2026-02-26 | Desert Medical Group | $201.00 | Approved |
| CLM-2026-030924 | 2025-12-08 | Lakeside Internal Medicine Associates | $232.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.