CLM-2026-028446
Unity Medical Group, Internal Medicine. Service 2026-06-11 at office (POS 11). Received 2026-07-10.
Member
Resolved through the identity graph
- Member
- Thomas Baker
- Member ID
- UHC-94453-11
- Date of birth
- 1955-02-04
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-422421
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3469
- Coverage period
- 2023-06-01 to present
- Deductible
- $559.31 of $1,000.0056%
- Out-of-pocket maximum
- $487.91 of $2,000.0024%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1276733437
- Network
- In network
- Rendering NPI
- 4407854957
- Location
- Dallas, TX · TIN 20-2485956
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $108.00 | $66.96 | $25.00 | $41.96 | Paid |
| Totals | $108.00 | $66.96 | $25.00 | $41.96 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-356616
- 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-003513 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-11: MEDICARE-ADV-A (MA), effective 2023-06-01. | |
| Timely filing | Pass | Received 29 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 (1276733437). | |
| 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 Group2026-06-11 16:34
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
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-2026-027711 | 2026-07-08 | Pinecrest Medical Group | $320.00 | Approved |
| CLM-2026-029837 | 2025-12-03 | Mesa Clinical Laboratories | $253.00 | 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
Clean claim, priced at contract rate.