CLM-2026-024631
Unity Medical Group, Internal Medicine. Service 2026-04-27 to 2026-04-30 at inpatient hospital (POS 21). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Carol Gutierrez
- Member ID
- UHC-45287-35
- Date of birth
- 2000-09-08
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-413675
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8694
- Coverage period
- 2025-12-01 to present
- Deductible
- $23.03 of $3,500.001%
- Out-of-pocket maximum
- $4,329.56 of $10,500.0041%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1276733437
- Network
- In network
- Rendering NPI
- 8022307622
- Location
- Dallas, TX · TIN 20-2485956
- 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 | $240.00 | $132.00 | $132.00 | $0.00 | Paid |
| Totals | $240.00 | $132.00 | $132.00 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-201426
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-04-27 to 2026-04-28
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003807 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-27: OPTIONS-PPO (PPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 20 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 Unity Medical Group (1276733437). | |
| 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: Unity Medical Group2026-04-30 17:45
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-201426.pdf8 pages
Itemised statement totalling $240.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024632 | 2026-04-27 | Meadow Internal Medicine Associates | $240.00 | Needs review |
| CLM-2026-018503 | 2026-05-20 | Summit Endocrine Associates | $386.00 | Needs review |
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
Clean claim, priced at contract rate.