Claims workbench/CLM-2026-025279

Institutional claim · UB-04 · EDI 837I

CLM-2026-025279

Desert Internal Medicine Associates, Internal Medicine. Service 2026-01-19 to 2026-01-20 at inpatient hospital (POS 21). Received 2026-01-31.

Needs review

Billed

$259.00

1 line

Allowed

$142.45

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Jessica Adams
Member ID: UHC-97802-47
Date of birth: 1961-07-22
Identity: Verified7 records, confidence 0.99
Claim record: CLMCLM-418595
Relationship: Self, Columbus, OH

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-6200
Coverage period: 2021-06-01 to 2026-02-06
Deductible: $1,729.68 of $2,500.0069%
Out-of-pocket maximum: $816.54 of $10,000.008%
Copays: office $30.00, specialist $75.00, emergency $350.00
Physical therapy visits: 21 of 20 used

Provider

Billing and rendering

Billing provider: Desert Internal Medicine Associates
Internal Medicine · taxonomy 207R00000X
NPI: 9861363924
Network: In network
Rendering NPI: 1904883273
Location: Tampa, FL · TIN 69-3872191
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	$259.00	$142.45	—	—	Review
Totals						$259.00	$142.45	—	—

Diagnoses (ICD-10-CM)

1. J44.9 COPD, unspecifiedprincipal
2. I10 Essential (primary) hypertension

Claim header

Patient account: PA-895626
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: 2026-01-19 to 2026-01-20
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-009046 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-01-19: NULL (PPO), effective 2021-06-01, terms 2026-02-06.
Timely filing	Pass		Received 11 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 (9861363924).
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: “Follow-up for copd, unspecified. Plan discussed, medications reconciled. Note dictated; si”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Desert Internal Medicine Associates2026-01-20 18:22
Follow-up for copd, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
SystemSystem: Claims system2026-01-31 04:20
Rendering provider signature missing on the attached note. Development letter sent to provider.

Attachments

Documents received with the claim

Itemized billitemized_PA-895626.pdf4 pages
Itemised statement totalling $259.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Completeness: Documentation incomplete: “Follow-up for copd, unspecified. Plan discussed, medications reconciled. Note dictated; si”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-022404	2026-06-29	Harbor Cardiovascular Associates	$671.00	Denied
CLM-2026-018723	2026-03-26	Northgate Reference Lab	$164.00	Denied
CLM-2026-005799	2026-03-27	Northgate Orthopedic Specialists	$37,463.00	Denied
CLM-2026-007161	2026-02-28	Meadow Primary Care Associates	$362.00	Denied

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity