CLM-2026-016930
Desert Medical Group, Internal Medicine. Service 2026-02-01 at office (POS 11). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Brian Vargas
- Member ID
- UHC-94455-80
- Date of birth
- 1977-11-09
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-400536
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5270
- Coverage period
- 2024-04-01 to present
- Deductible
- $1,047.21 of $3,500.0030%
- Out-of-pocket maximum
- $4,624.07 of $10,500.0044%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4556045621
- Network
- In network
- Rendering NPI
- 7747879790
- Location
- Scottsdale, AZ · TIN 56-2756422
- 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 | $101.00 | $62.62 | $40.00 | $22.62 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $282.00 | $174.84 | $0.00 | $174.84 | Paid |
| Totals | $383.00 | $237.46 | $40.00 | $197.46 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-465655
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017397 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-01: SELECT-EPO (EPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 31 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 Medical Group (4556045621). | |
| 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 Medical Group2026-02-01 12:08
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.