CLM-2026-022262
Unity Internal Medicine Associates, Internal Medicine. Service 2026-10-01 to 2026-10-04 at inpatient hospital (POS 21). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Justin Pena
- Member ID
- UHC-23865-08
- Date of birth
- 1953-06-20
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-412757
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3314
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,040.53 of $1,500.0069%
- Out-of-pocket maximum
- $1,014.32 of $3,000.0034%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8984483692
- Network
- Out of network
- Rendering NPI
- 9156374552
- Location
- Atlanta, GA · TIN 10-7193981
- 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 | $218.00 | $98.10 | — | — | Review |
| Totals | $218.00 | $98.10 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-459486
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-10-01 to 2026-10-03
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012071 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-10-01: MEDICARE-ADV-A (MA), effective 2022-08-01. | |
| Timely filing | Pass | Received 7 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms re”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Internal Medicine Associates2026-10-04 09:14
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-10-11 06:58
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-459486.pdf3 pages
Itemised statement totalling $218.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms re”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.