CLM-2026-029443
Desert Medical Group, Internal Medicine. Service 2026-01-18 at office (POS 11). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Hiroshi Dominguez
- Member ID
- UHC-44104-03
- Date of birth
- 1993-05-22
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-421694
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1271
- Coverage period
- 2022-09-01 to 2026-04-25
- Deductible
- $1,468.20 of $3,500.0042%
- Out-of-pocket maximum
- $731.07 of $7,000.0010%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5303428622
- Network
- In network
- Rendering NPI
- 2816841144
- Location
- Atlanta, GA · TIN 67-2719316
- 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 | $112.00 | $69.44 | $20.00 | $49.44 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $359.00 | $222.58 | $0.00 | $222.58 | Paid |
| Totals | $471.00 | $292.02 | $20.00 | $272.02 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-168134
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017224 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-18: SELECT-EPO (EPO), effective 2022-09-01, terms 2026-04-25. | |
| Timely filing | Pass | Received 44 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 Medical Group (5303428622). | |
| 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 Medical Group2026-01-18 15:06
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 engineApproved2026-10-22 12:44Clean 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.