CLM-2026-023070
Valley Medical Group, Internal Medicine. Service 2026-05-08 to 2026-05-10 at inpatient hospital (POS 21). Received 2026-06-05.
Member
Resolved through the identity graph
- Member
- Bryan Jenkins
- Member ID
- UHC-40066-17
- Date of birth
- 1945-05-18
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-419660
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5445
- Coverage period
- 2025-09-01 to present
- Deductible
- $141.10 of $3,500.004%
- Out-of-pocket maximum
- $2,205.74 of $7,000.0032%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1946396904
- Network
- In network
- Rendering NPI
- 5699536491
- Location
- Nashville, TN · TIN 16-4753822
- Authorisation / referral
- none / REF716336
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 | $226.00 | $124.30 | — | — | Review |
| Totals | $226.00 | $124.30 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-656841
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-08 to 2026-05-09
- 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-007846 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-08: NAVIGATE-HMO (HMO), effective 2025-09-01. | |
| Timely filing | Pass | Received 26 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 Valley Medical Group (1946396904). | |
| 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: “Patient seen for essential (primary) hypertension. Note dictated; signature pending.”. 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: Valley Medical Group2026-05-10 09:41
Patient seen for essential (primary) hypertension. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-05 02:46
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-05 14:28
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-656841.pdf2 pages
Itemised statement totalling $226.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for essential (primary) hypertension. Note dictated; signature pending.”.
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.