CLM-2026-022287
Desert Diabetes Center, Endocrinology. Service 2026-04-20 at office (POS 11). Received 2026-05-06.
Member
Resolved through the identity graph
- Member
- Bradley Weaver
- Member ID
- UHC-93569-57
- Date of birth
- 1986-04-15
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-407132
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1603
- Coverage period
- 2025-01-01 to 2026-02-18
- Deductible
- $934.19 of $3,500.0027%
- Out-of-pocket maximum
- $6,139.22 of $14,000.0044%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4143565768
- Network
- In network
- Rendering NPI
- 8316061661
- Location
- Phoenix, AZ · TIN 51-1868485
- Authorisation / referral
- none / REF451468
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 | $429.00 | $265.98 | — | — | DeniedCO27 |
| 2 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 2 | $191.00 | $118.42 | — | — | DeniedCO27 |
| Totals | $620.00 | $384.40 | — | — | ||||||
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-458870
- 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-001971 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-20 is after coverage terminated on 2026-02-18. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 16 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 Diabetes Center (4143565768). | |
| 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 Diabetes Center2026-04-20 10:26
Follow-up for hypothyroidism, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-06 05:53
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-06 08:06
Member services inquiry logged on this claim; member asked about the status of payment.
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 2026-04-20 is after coverage terminated on 2026-02-18.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011152 | 2025-12-25 | Meadow Medical Group | $514.00 | 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.