CLM-2026-020694
Desert Medical Group, Internal Medicine. Service 2026-07-22 at office (POS 11). Received 2026-09-12.
Member
Resolved through the identity graph
- Member
- Samuel Fields
- Member ID
- UHC-70900-77
- Date of birth
- 1973-02-01
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-419657
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0117
- Coverage period
- 2023-01-01 to present
- Deductible
- $605.98 of $1,500.0040%
- Out-of-pocket maximum
- $2,688.10 of $6,000.0045%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5303428622
- Network
- In network
- Rendering NPI
- 9400185770
- Location
- Atlanta, GA · TIN 67-2719316
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $227.00 | $140.74 | — | — | DeniedCO18 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $46.00 | $28.52 | — | — | DeniedCO18 |
| Totals | $273.00 | $169.26 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-610310
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013967 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-22: NULL (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 52 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-020693: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Medical Group (5303428622). | |
| 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 Group2026-07-22 18:59
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-12 02:45
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-020693: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020693 | 2026-07-22 | Desert Medical Group | $273.00 | Approved |
| CLM-2026-014053 | 2026-07-11 | Riverside Internal Medicine Associates | $298.00 | Approved |
| CLM-2026-004290 | 2026-06-16 | Canyon Reference Lab | $106.00 | Approved |
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
Exact duplicate of an earlier submission.