CLM-2026-021924
Valley Internal Medicine Associates, Internal Medicine. Service 2026-01-08 to 2026-01-09 at inpatient hospital (POS 21). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Vincent Gomez
- Member ID
- UHC-91184-90
- Date of birth
- 1987-11-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409219
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-4688
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,331.02 of $2,500.0053%
- Out-of-pocket maximum
- $4,759.99 of $10,000.0048%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5095030487
- Network
- In network
- Rendering NPI
- 1762460594
- 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 | $233.00 | $128.15 | — | — | DeniedCO29 |
| Totals | $233.00 | $128.15 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-753972
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-08 to 2026-01-12
- 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-025742 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-08: N/A (PPO), effective 2024-05-01. | |
| Timely filing | Fail | CO29 | Received 95 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Associates2026-01-09 18:35
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-04-14 02:24
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-753972.pdf7 pages
Itemised statement totalling $233.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 95 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010243 | 2026-10-13 | Mesa Reference Lab | $40.00 | Approved |
| CLM-2026-001390 | 2026-06-08 | Mesa Reference Lab | $89.00 | 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
Received after the timely-filing limit.