CLM-2026-015960
Unity Internal Medicine Associates, Internal Medicine. Service 2026-08-28 to 2026-08-31 at inpatient hospital (POS 21). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Susan Ward
- Member ID
- UHC-82540-45
- Date of birth
- 1976-10-13
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-426779
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0434
- Coverage period
- 2024-04-01 to 2026-02-16
- Deductible
- $305.57 of $500.0061%
- Out-of-pocket maximum
- $894.62 of $2,000.0045%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8984483692
- Network
- Out of network
- Rendering NPI
- 9655949102
- Location
- Atlanta, GA · TIN 10-7193981
- Authorisation / referral
- none / REF999577
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 | $188.00 | $84.60 | — | — | DeniedCO27 |
| Totals | $188.00 | $84.60 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-599071
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-28 to 2026-09-01
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000634 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-28 is after coverage terminated on 2026-02-16. 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 | Fail | CO204 | Billing provider 8984483692 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Unity Internal Medicine Associates2026-08-31 17:28
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-09-05 05:13
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-05 17:06
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-599071.pdf8 pages
Itemised statement totalling $188.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-28 is after coverage terminated on 2026-02-16. Provider network: Billing provider 8984483692 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022228 | 2026-03-12 | Sunrise Behavioral Health | $317.00 | Denied |
| CLM-2026-000914 | 2025-12-23 | Sunrise Dermatology Clinic | $614.00 | 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.