CLM-2026-030342
Desert Internal Medicine Associates, Internal Medicine. Service 2026-04-21 to 2026-04-22 at inpatient hospital (POS 21). Received 2026-04-23.
Member
Resolved through the identity graph
- Member
- Jacqueline Williams
- Member ID
- UHC-10689-03
- Date of birth
- 1947-08-08
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-409006
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0741
- Coverage period
- 2025-07-01 to present
- Deductible
- $696.54 of $3,500.0020%
- Out-of-pocket maximum
- $1,019.07 of $7,000.0015%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5106489862
- Network
- In network
- Rendering NPI
- 3124330929
- Location
- Houston, TX · TIN 11-1256116
- Authorisation / referral
- none / none
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 | $232.00 | $127.60 | $127.60 | $0.00 | Paid |
| Totals | $232.00 | $127.60 | $127.60 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-508446
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-04-21 to 2026-04-22
- 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-011346 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-21: MEDICARE-ADV-B (MA), effective 2025-07-01. | |
| Timely filing | Pass | Received 1 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 (5106489862). | |
| 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 Associates2026-04-22 18:24
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-508446.pdf3 pages
Itemised statement totalling $232.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024130 | 2026-07-28 | Summit Family Practice | $32.00 | Approved |
| CLM-2026-007975 | 2026-05-20 | Sunrise Skin Care Associates | $296.00 | Needs review |
| CLM-2026-030343 | 2026-04-21 | Desert Internal Medicine Associates | $232.00 | Needs review |
| CLM-2026-010621 | 2026-01-04 | Mesa Clinical Laboratories | $48.00 | Approved |
| CLM-2026-017897 | 2025-12-31 | Harbor Medical Group | $360.00 | 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.