CLM-2026-013753
Desert Medical Group, Internal Medicine. Service 2026-05-15 to 2026-05-19 at inpatient hospital (POS 21). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Joshua Hayes
- Member ID
- none on golden record
- Date of birth
- 1956-04-13
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407954
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-1321
- Coverage period
- 2023-11-01 to present
- Deductible
- $177.83 of $500.0036%
- Out-of-pocket maximum
- $239.23 of $2,000.0012%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4556045621
- Network
- In network
- Rendering NPI
- 5285873142
- Location
- Scottsdale, AZ · TIN 56-2756422
- 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 | $251.00 | $138.05 | — | — | PendedIDQ |
| Totals | $251.00 | $138.05 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-198308
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-15 to 2026-05-17
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002363; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-15: OPTIONS-PPO (PPO), effective 2023-11-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 1 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 (4556045621). | |
| 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 Group2026-05-19 18:02
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-198308.pdf4 pages
Itemised statement totalling $251.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002363; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-15: OPTIONS-PPO (PPO), effective 2023-11-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.