CLM-2026-020505
Desert Medical Group, Internal Medicine. Service 2026-02-09 to 2026-02-12 at inpatient hospital (POS 21). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Julie Wilson
- Member ID
- UHC-76381-41
- Date of birth
- 1990-10-20
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-412037
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8288
- Coverage period
- 2023-05-01 to present
- Deductible
- $1,851.97 of $2,500.0074%
- Out-of-pocket maximum
- $2,193.75 of $5,000.0044%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3427053921
- Network
- In network
- Rendering NPI
- 8924809667
- Location
- San Diego, CA · TIN 22-6599572
- Authorisation / referral
- none / none
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 | $170.00 | $93.50 | $93.50 | $0.00 | Paid |
| Totals | $170.00 | $93.50 | $93.50 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-951514
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-02-09 to 2026-02-13
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020730 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-09: SELECT-EPO (EPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 39 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 (3427053921). | |
| 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 Group2026-02-12 13:30
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-951514.pdf9 pages
Itemised statement totalling $170.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004240 | 2026-09-05 | Valley Internal Medicine Associates | $74.00 | Approved |
| CLM-2026-020892 | 2026-06-30 | Lakeside Medical Group | $240.00 | Denied |
| CLM-2026-026607 | 2026-02-25 | Lakeside Orthopedic Specialists | $34,639.00 | Denied |
| CLM-2026-026606 | 2026-02-25 | Lakeside Orthopedic Specialists | $34,639.00 | 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.