CLM-2026-019350
Desert Medical Group, Internal Medicine. Service 2026-05-01 at office (POS 11). Received 2026-05-04.
Member
Resolved through the identity graph
- Member
- Virginia Harvey
- Member ID
- UHC-73952-53
- Date of birth
- 1957-05-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-416048
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6759
- Coverage period
- 2025-08-01 to 2026-02-12
- Deductible
- $220.94 of $500.0044%
- Out-of-pocket maximum
- $68.50 of $1,000.007%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4556045621
- Network
- In network
- Rendering NPI
- 2103646198
- 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 | $88.00 | $54.56 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $58.00 | $35.96 | — | — | DeniedCO27 |
| Totals | $146.00 | $90.52 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-203561
- 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-004160 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-01 is after coverage terminated on 2026-02-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 Group2026-05-01 14:23
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-04 05:48
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-01 is after coverage terminated on 2026-02-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025520 | 2026-06-11 | Canyon Regional Medical Center | $1,350.00 | 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.