CLM-2026-019947
Desert Internal Medicine Associates, Internal Medicine. Service 2026-06-02 at office (POS 11). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Austin Murray
- Member ID
- UHC-81322-23
- Date of birth
- 1950-07-01
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414579
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2418
- Coverage period
- 2024-08-01 to 2026-01-13
- Deductible
- $1,900.84 of $3,500.0054%
- Out-of-pocket maximum
- $1,216.41 of $7,000.0017%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9861363924
- Network
- In network
- Rendering NPI
- 3229412689
- Location
- Tampa, FL · TIN 69-3872191
- 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 | $103.00 | $63.86 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $235.00 | $145.70 | — | — | DeniedCO27 |
| 3 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $334.00 | $207.08 | — | — | DeniedCO27 |
| Totals | $672.00 | $416.64 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-779233
- 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-035296 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-02 is after coverage terminated on 2026-01-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 15 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 (9861363924). | |
| 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 Associates2026-06-02 11:56
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-17 06:49
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 2026-06-02 is after coverage terminated on 2026-01-13.
Other claims for this member
Same resolved identity
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.