CLM-2026-027659
Desert Internal Medicine Associates, Internal Medicine. Service 2026-08-24 at office (POS 11). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Janice Washington
- Member ID
- UHC-80769-32
- Date of birth
- 2003-02-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412832
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5937
- Coverage period
- 2023-05-01 to present
- Deductible
- $172.55 of $1,000.0017%
- Out-of-pocket maximum
- $982.01 of $2,000.0049%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9861363924
- Network
- In network
- Rendering NPI
- 4011881164
- Location
- Tampa, FL · TIN 69-3872191
- 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 | — | 1 | 1 | $252.00 | $156.24 | $30.00 | $126.24 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $82.00 | $50.84 | $0.00 | $50.84 | Paid |
| Totals | $334.00 | $207.08 | $30.00 | $177.08 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-171145
- 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-003809 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-24: MEDICARE-ADV-B (MA), effective 2023-05-01. | |
| Timely filing | Pass | Received 31 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 | 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 Associates2026-08-24 11:05
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-09-24 00:48
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-24 09:54
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-171145.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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-2026-023585 | 2026-08-11 | Canyon Cardiovascular Associates | $454.00 | Approved |
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
Authorisation must be confirmed with UM before payment.