CLM-2026-014614
Desert Internal Medicine Associates, Internal Medicine. Service 2026-07-12 at office (POS 11). Received 2026-07-17.
Member
Resolved through the identity graph
- Member
- Adam Turner
- Member ID
- UHC-00556-15
- Date of birth
- 1959-06-10
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-409590
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3334
- Coverage period
- 2023-07-01 to 2026-06-16
- Deductible
- $1,267.91 of $1,500.0085%
- Out-of-pocket maximum
- $1,484.61 of $3,000.0049%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9861363924
- Network
- In network
- Rendering NPI
- 4446211631
- Location
- Tampa, FL · TIN 69-3872191
- Authorisation / referral
- none / none
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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $79.00 | $48.98 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $51.00 | $31.62 | — | — | DeniedCO27 |
| Totals | $130.00 | $80.60 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-711546
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-025635 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-12 is after coverage terminated on 2026-06-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 (9861363924). | |
| 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 Associates2026-07-12 14:50
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-17 01:45
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-17 11:48
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-12 is after coverage terminated on 2026-06-16.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003239 | 2026-04-17 | Heritage Family Practice | $382.00 | 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.