CLM-2026-018006
Desert Internal Medicine Associates, Internal Medicine. Service 2026-03-30 to 2026-04-01 at inpatient hospital (POS 21). Received 2026-04-21.
Member
Resolved through the identity graph
- Member
- Pamela Lucas
- Member ID
- UHC-85455-92
- Date of birth
- 1939-05-07
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-411887
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5824
- Coverage period
- 2022-02-01 to 2026-01-17
- Deductible
- $1,186.98 of $2,500.0047%
- Out-of-pocket maximum
- $2,909.14 of $10,000.0029%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5106489862
- Network
- In network
- Rendering NPI
- 8735102633
- Location
- Houston, TX · TIN 11-1256116
- Authorisation / referral
- none / REF556741
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 | $175.00 | $96.25 | — | — | DeniedCO27 |
| Totals | $175.00 | $96.25 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-854143
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-30 to 2026-04-01
- 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-022043 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-30 is after coverage terminated on 2026-01-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 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 | 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 Associates2026-04-01 18:31
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-21 01:41
Attachments
Documents received with the claim
- Itemized billitemized_PA-854143.pdf7 pages
Itemised statement totalling $175.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-30 is after coverage terminated on 2026-01-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017205 | 2026-03-29 | Summit Endocrine Associates | $71.00 | Denied |
| CLM-2026-014242 | 2026-03-03 | Valley Primary Care Associates | $520.00 | Denied |
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.