CLM-2026-026914
Desert Internal Medicine Associates, Internal Medicine. Service 2026-01-23 to 2026-01-25 at inpatient hospital (POS 21). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Kelly Vazquez
- Member ID
- UHC-86573-18
- Date of birth
- 1940-03-23
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427832
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5832
- Coverage period
- 2021-01-01 to present
- Deductible
- $741.51 of $1,000.0074%
- Out-of-pocket maximum
- $260.39 of $2,000.0013%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 3013140306
- Network
- In network
- Rendering NPI
- 6597989626
- Location
- Tempe, AZ · TIN 35-1948033
- Authorisation / referral
- none / REF946694
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 | $255.00 | $140.25 | $140.25 | $0.00 | Paid |
| Totals | $255.00 | $140.25 | $140.25 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-633289
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-23 to 2026-01-26
- 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-016955 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-23: CORE-HMO (HMO), effective 2021-01-01. | |
| Timely filing | Pass | Received 36 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 (3013140306). | |
| 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 Associates2026-01-25 14:58
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-633289.pdf7 pages
Itemised statement totalling $255.00 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-2026-024377 | 2026-06-05 | Unity Internal Medicine Associates | $172.00 | Denied |
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.