CLM-2026-020870
Valley Internal Medicine Associates, Internal Medicine. Service 2026-05-31 to 2026-06-01 at inpatient hospital (POS 21). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Walter Sanchez
- Member ID
- UHC-28330-36
- Date of birth
- 1997-08-25
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-410092
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9870
- Coverage period
- 2021-02-01 to 2026-05-26
- Deductible
- $28.15 of $2,500.001%
- Out-of-pocket maximum
- $2,826.75 of $7,500.0038%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5095030487
- Network
- In network
- Rendering NPI
- 2134686361
- Location
- Charlotte, NC · TIN 47-3292895
- 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 | $256.00 | $140.80 | — | — | DeniedCO27 |
| Totals | $256.00 | $140.80 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-863960
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-31 to 2026-06-01
- 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-033557 (provisional, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-31 is after coverage terminated on 2026-05-26. 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 Valley Internal Medicine Associates (5095030487). | |
| 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: Valley Internal Medicine Associates2026-06-01 09:43
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-04 05:18
Attachments
Documents received with the claim
- Itemized billitemized_PA-863960.pdf7 pages
Itemised statement totalling $256.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-31 is after coverage terminated on 2026-05-26.
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.