CLM-2026-017776
Unity Medical Group, Internal Medicine. Service 2026-01-20 to 2026-01-24 at inpatient hospital (POS 21). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Willie Lawrence
- Member ID
- UHC-44326-19
- Date of birth
- 1981-01-26
- Identity
- Verified3 records, confidence 0.91
- Claim record
- CLMCLM-403811
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3910
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,342.01 of $1,500.0089%
- Out-of-pocket maximum
- $1,129.96 of $3,000.0038%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1355996814
- Network
- In network
- Rendering NPI
- 2682267226
- Location
- Mesa, AZ · TIN 43-9161942
- Authorisation / referral
- none / REF242679
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 | $186.00 | $102.30 | $102.30 | $0.00 | Paid |
| Totals | $186.00 | $102.30 | $102.30 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-783265
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-20 to 2026-01-24
- 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-015149 (verified, link confidence 0.91). | |
| Eligibility | Pass | Active on 2026-01-20: CORE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Pass | Received 29 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 Unity Medical Group (1355996814). | |
| 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 Medical Group2026-01-24 18:40
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-783265.pdf7 pages
Itemised statement totalling $186.00 across 1 line.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015416 | 2026-05-09 | Unity Counseling Center | $422.00 | Approved |
| CLM-2026-017777 | 2026-01-20 | Mesa Internal Medicine Associates | $186.00 | Needs review |
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.