CLM-2026-027036
Desert Internal Medicine Associates, Internal Medicine. Service 2026-04-19 at office (POS 11). Received 2026-05-08.
Member
Resolved through the identity graph
- Member
- Nicole Carter
- Member ID
- UHC-16666-12
- Date of birth
- 1978-02-06
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-409164
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2105
- Coverage period
- 2025-12-01 to present
- Deductible
- $265.95 of $1,500.0018%
- Out-of-pocket maximum
- $2,028.61 of $6,000.0034%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6778439607
- Network
- In network
- Rendering NPI
- 2888146141
- Location
- Mesa, AZ · TIN 70-7613029
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $42.00 | $26.04 | $25.00 | $1.04 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $382.00 | $236.84 | $0.00 | $236.84 | Paid |
| Totals | $424.00 | $262.88 | $25.00 | $237.88 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-884347
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-010513 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-19: MEDICARE-ADV-A (MA), effective 2025-12-01. | |
| Timely filing | Pass | Received 19 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 (6778439607). | |
| 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 Associates2026-04-19 13:01
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
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-2026-002419 | 2026-08-20 | Valley Primary Care Associates | $711.00 | Approved |
| CLM-2026-006848 | 2025-11-23 | Canyon Regional Medical Center | $1,011.00 | 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.