CLM-2026-015233
Desert Diabetes Center, Endocrinology. Service 2026-03-22 at office (POS 11). Received 2026-04-24.
Member
Resolved through the identity graph
- Member
- Frances Boyd
- Member ID
- UHC-09027-77
- Date of birth
- 1980-05-19
- Identity
- Verified2 records, confidence 0.98
- Claim record
- CLMCLM-424605
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9181
- Coverage period
- 2021-12-01 to 2026-03-21
- Deductible
- $1,416.65 of $2,500.0057%
- Out-of-pocket maximum
- $143.38 of $5,000.003%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4143565768
- Network
- In network
- Rendering NPI
- 3548711480
- Location
- Phoenix, AZ · TIN 51-1868485
- 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 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $197.00 | $122.14 | — | — | DeniedCO27 |
| Totals | $197.00 | $122.14 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. E05.90 Thyrotoxicosis, unspecified
- Patient account
- PA-902536
- 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-021034 (verified, link confidence 0.98). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-22 is after coverage terminated on 2026-03-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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 Diabetes Center (4143565768). | |
| 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 Diabetes Center2026-03-22 16:33
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-24 05:59
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-24 11:49
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-22 is after coverage terminated on 2026-03-21.
Other claims for this member
Same resolved identity
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.