CLM-2026-022659
Desert Medical Group, Family Medicine. Service 2026-03-02 at office (POS 11). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Maria Wells
- Member ID
- UHC-83588-76
- Date of birth
- 2005-07-01
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-421932
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3375
- Coverage period
- 2023-08-01 to present
- Deductible
- $422.44 of $1,000.0042%
- Out-of-pocket maximum
- $398.73 of $3,000.0013%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6663550666
- Network
- In network
- Rendering NPI
- 7234857523
- Location
- Mesa, AZ · TIN 39-6249973
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $192.00 | $119.04 | — | — | DeniedCO29 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $314.00 | $194.68 | — | — | DeniedCO29 |
| Totals | $506.00 | $313.72 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-130280
- 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-012710 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-02: NAVIGATE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Fail | CO29 | Received 102 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 Desert Medical Group (6663550666). | |
| 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 Medical Group2026-03-02 18:31
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-12 03:57
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
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 102 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011768 | 2026-08-31 | Lakeside Bone and Joint Center | $33,484.00 | Needs review |
| CLM-2026-001506 | 2026-02-02 | Heritage Medical Group | $613.00 | Denied |
| CLM-2026-001505 | 2026-02-02 | Heritage Medical Group | $613.00 | Approved |
| CLM-2026-019498 | 2026-01-02 | Canyon Diagnostic Imaging | $542.00 | Needs review |
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.