CLM-2026-021952
Desert Internal Medicine Associates, Internal Medicine. Service 2026-10-10 at office (POS 11). Received 2026-10-16.
Member
Resolved through the identity graph
- Member
- Anthony Fields
- Member ID
- UHC-31856-02
- Date of birth
- 2004-11-14
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-418631
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4657
- Coverage period
- 2024-10-01 to 2026-08-15
- Deductible
- $163.89 of $500.0033%
- Out-of-pocket maximum
- $264.71 of $1,000.0026%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 3013140306
- Network
- In network
- Rendering NPI
- 2052419183
- Location
- Tempe, AZ · TIN 35-1948033
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $322.00 | $199.64 | — | — | DeniedCO27 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $73.00 | $45.26 | — | — | DeniedCO27 |
| Totals | $395.00 | $244.90 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-904335
- 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-031536 (verified, link confidence 0.98). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-10 is after coverage terminated on 2026-08-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 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 (3013140306). | |
| 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 Associates2026-10-10 15:08
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-10-16 00:39
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-16 09:30
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-10-10 is after coverage terminated on 2026-08-15.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017187 | 2026-06-20 | Lakeside Imaging Center | $3,146.00 | 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
Service after coverage termination.