CLM-2026-015926
Desert Internal Medicine Associates, Internal Medicine. Service 2025-10-08 at office (POS 11). Received 2026-05-10.
Member
Resolved through the identity graph
- Member
- Jacob Brown
- Member ID
- UHC-55032-13
- Date of birth
- 1984-09-17
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-403629
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4699
- Coverage period
- 2022-07-01 to present
- Deductible
- $228.08 of $1,000.0023%
- Out-of-pocket maximum
- $577.39 of $3,000.0019%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9861363924
- Network
- In network
- Rendering NPI
- 8757952519
- 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 | $62.00 | $38.44 | — | — | DeniedCO29 |
| Totals | $62.00 | $38.44 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-900220
- 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-030070 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-08: OPTIONS-PPO (PPO), effective 2022-07-01. | |
| Timely filing | Fail | CO29 | Received 214 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Associates2025-10-08 14:59
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-05-10 06:45
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-10 10:59
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 engineDenied2026-10-22 12:44Timely filing: Received 214 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014910 | 2026-07-12 | Meadow Family Practice | $294.00 | 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
Received after the timely-filing limit.