CLM-2026-026477
Unity Medical Group, Internal Medicine. Service 2025-12-22 to 2025-12-23 at inpatient hospital (POS 21). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Ahmed Jacobs
- Member ID
- UHC-99057-32
- Date of birth
- 1982-06-07
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-410716
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5060
- Coverage period
- 2024-10-01 to present
- Deductible
- $2,044.21 of $3,500.0058%
- Out-of-pocket maximum
- $1,884.56 of $7,000.0027%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1355996814
- Network
- In network
- Rendering NPI
- 5767211589
- Location
- Mesa, AZ · TIN 43-9161942
- 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. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-173850
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-12-22 to 2025-12-23
- 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-001851 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-22: SELECT-EPO (EPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 14 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 (1355996814). | |
| 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 Group2025-12-23 10:36
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-173850.pdf5 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
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.