CLM-2026-013759
Desert Medical Group, Internal Medicine. Service 2026-03-25 at office (POS 11). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- Christine Le
- Member ID
- UHC-06546-55
- Date of birth
- 1976-04-22
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-424743
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9167
- Coverage period
- 2024-09-01 to present
- Deductible
- $243.49 of $1,000.0024%
- Out-of-pocket maximum
- $1,603.71 of $4,000.0040%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4556045621
- Network
- In network
- Rendering NPI
- 4899747966
- Location
- Scottsdale, AZ · TIN 56-2756422
- Authorisation / referral
- none / REF240542
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $284.00 | $176.08 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $62.00 | $38.44 | — | — | Review |
| Totals | $346.00 | $214.52 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-742341
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-010077 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-25: CORE-HMO (HMO), effective 2024-09-01. | |
| Timely filing | Pass | Received 10 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 | Review | CO16 | Documentation incomplete: “Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Medical Group2026-03-25 16:18
Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.
- SystemSystem: Claims system2026-04-04 05:02
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-04 16:22
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025888 | 2026-01-29 | Pinecrest Regional Medical Center | $1,156.00 | Needs review |
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
Development letter outstanding.