CLM-2026-011350
Valley Medical Group, Internal Medicine. Service 2025-12-09 to 2025-12-13 at inpatient hospital (POS 21). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Peter Robertson
- Member ID
- UHC-65809-32
- Date of birth
- 2003-07-16
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-401207
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9667
- Coverage period
- 2024-12-01 to 2026-04-14
- Deductible
- $813.35 of $1,500.0054%
- Out-of-pocket maximum
- $271.75 of $4,500.006%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1946396904
- Network
- In network
- Rendering NPI
- 2777628530
- Location
- Nashville, TN · TIN 16-4753822
- Authorisation / referral
- none / none
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 | $253.00 | $139.15 | $139.15 | $0.00 | Paid |
| Totals | $253.00 | $139.15 | $139.15 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-616318
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-12-09 to 2025-12-11
- 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-003315 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-09: - (PPO), effective 2024-12-01, terms 2026-04-14. | |
| Timely filing | Pass | Received 29 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 Valley Medical Group (1946396904). | |
| 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: Valley Medical Group2025-12-13 14:33
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-11 01:01
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-616318.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-616318.pdf3 pages
Itemised statement totalling $253.00 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
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
Authorisation must be confirmed with UM before payment.