CLM-2026-013917
Desert Internal Medicine Associates, Internal Medicine. Service 2026-07-09 to 2026-07-13 at inpatient hospital (POS 21). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- Nicholas Santos
- Member ID
- UHC-65934-13
- Date of birth
- 1973-05-25
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-428415
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3756
- Coverage period
- 2024-12-01 to 2026-02-12
- Deductible
- $132.33 of $500.0026%
- Out-of-pocket maximum
- $731.45 of $2,000.0037%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 3013140306
- Network
- In network
- Rendering NPI
- 6436362845
- Location
- Tempe, AZ · TIN 35-1948033
- 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 | $215.00 | $118.25 | — | — | DeniedCO27 |
| Totals | $215.00 | $118.25 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-405790
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-09 to 2026-07-13
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001937 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-09 is after coverage terminated on 2026-02-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 41 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 (3013140306). | |
| 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 Associates2026-07-13 17:01
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-23 00:28
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-23 10:00
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-405790.pdf6 pages
Itemised statement totalling $215.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-09 is after coverage terminated on 2026-02-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023380 | 2025-10-21 | Summit Medical Group | $662.00 | Denied |
| CLM-2026-022342 | 2025-12-25 | Heritage GI Associates | $2,257.00 | Denied |
| CLM-2026-022341 | 2025-12-25 | Heritage GI Associates | $2,257.00 | Approved |
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.