CLM-2026-015795
Desert Internal Medicine Associates, Internal Medicine. Service 2026-04-05 to 2026-04-09 at inpatient hospital (POS 21). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Rchard Welch
- Member ID
- UHC-94329-01
- Date of birth
- 1944-11-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414081
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2299
- Coverage period
- 2021-10-01 to present
- Deductible
- $516.55 of $1,000.0052%
- Out-of-pocket maximum
- $963.59 of $2,000.0048%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5106489862
- Network
- In network
- Rendering NPI
- 3701271546
- Location
- Houston, TX · TIN 11-1256116
- 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 | $230.00 | $126.50 | — | — | Review |
| Totals | $230.00 | $126.50 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-229690
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-04-05 to 2026-04-06
- 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-006531 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-05: SELECT-EPO (EPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 28 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 (5106489862). | |
| 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: “Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Not”. 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 Internal Medicine Associates2026-04-09 18:47
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-07 06:04
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-07 12:20
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-229690.pdf5 pages
Itemised statement totalling $230.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Not”.
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
Development letter outstanding.