CLM-2026-013011
Desert Internal Medicine Associates, Internal Medicine. Service 2026-07-20 to 2026-07-22 at inpatient hospital (POS 21). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Keith Silva
- Member ID
- UHC-11375-71
- Date of birth
- 1987-02-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-424799
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group UNKNOWN
- Coverage period
- 2024-06-01 to 2026-06-18
- Deductible
- $467.10 of $2,500.0019%
- Out-of-pocket maximum
- $1,040.82 of $7,500.0014%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5106489862
- Network
- In network
- Rendering NPI
- 8821303285
- Location
- Houston, TX · TIN 11-1256116
- 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 | $200.00 | $110.00 | — | — | DeniedCO27 |
| Totals | $200.00 | $110.00 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-184466
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-20 to 2026-07-24
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038893 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-20 is after coverage terminated on 2026-06-18. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 9 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 Internal Medicine Associates (5106489862). | |
| 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 Internal Medicine Associates2026-07-22 12:27
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-31 02:48
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-31 11:26
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-184466.pdf5 pages
Itemised statement totalling $200.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-20 is after coverage terminated on 2026-06-18.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007481 | 2026-07-26 | Unity Cardiovascular Associates | $617.00 | Denied |
| CLM-2026-013677 | 2026-07-17 | Meadow Clinical Laboratories | $1,890.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.