CLM-2026-024166
Desert Internal Medicine Associates, Internal Medicine. Service 2026-04-12 to 2026-04-13 at inpatient hospital (POS 21). Received 2026-05-12.
Member
Resolved through the identity graph
- Member
- Alice Robinson
- Member ID
- UHC-97366-44
- Date of birth
- 1955-12-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403764
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3417
- Coverage period
- 2025-01-01 to present
- Deductible
- $883.53 of $1,500.0059%
- Out-of-pocket maximum
- $2,532.13 of $6,000.0042%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5106489862
- Network
- In network
- Rendering NPI
- 5804607575
- Location
- Houston, TX · TIN 11-1256116
- 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 | $258.00 | $141.90 | $141.90 | $0.00 | Paid |
| Totals | $258.00 | $141.90 | $141.90 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-905312
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-04-12 to 2026-04-14
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011432 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-12: OPTIONS-PPO (PPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 29 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 (5106489862). | |
| 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 Associates2026-04-13 16:17
Patient seen for type 2 diabetes mellitus with hyperglycemia. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-12 00:23
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-12 11:39
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-905312.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-905312.pdf4 pages
Itemised statement totalling $258.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032791 | 2026-06-23 | Pinecrest GI Associates | $3,435.00 | Needs review |
| CLM-2026-030074 | 2026-02-26 | Evergreen Primary Care Associates | $208.00 | Approved |
| CLM-2026-004607 | 2026-02-03 | Pinecrest GI Associates | $282.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.