CLM-2026-025228
Desert Medical Group, Internal Medicine. Service 2026-06-05 at office (POS 11). Received 2026-07-03.
Member
Resolved through the identity graph
- Member
- Rebecca Carpenter
- Member ID
- UHC-36683-87
- Date of birth
- 1995-11-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414282
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-2230
- Coverage period
- 2025-06-01 to present
- Deductible
- $651.80 of $2,500.0026%
- Out-of-pocket maximum
- $2,425.23 of $5,000.0049%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4556045621
- Network
- In network
- Rendering NPI
- 7231179947
- Location
- Scottsdale, AZ · TIN 56-2756422
- 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 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $275.00 | $170.50 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1 | $398.00 | $246.76 | — | — | Review |
| Totals | $673.00 | $417.26 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-598018
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-037086 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-05: UNKNOWN (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 28 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 Medical Group (4556045621). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2026-06-05 13:04
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-07-03 00:08
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-598018.pdf9 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendation recordedcli_adjudicator2026-10-21 13:39 · 1e217ea2
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
Bundled code pair; modifier 59 not supported by the operative note.