CLM-2026-030708
Desert Diabetes Center, Endocrinology. Service 2026-06-15 at office (POS 11). Received 2026-07-16.
Member
Resolved through the identity graph
- Member
- Julia Banks
- Member ID
- UHC-28147-69
- Date of birth
- 1999-05-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-402009
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9187
- Coverage period
- 2025-02-01 to present
- Deductible
- $121.88 of $1,500.008%
- Out-of-pocket maximum
- $1,328.24 of $6,000.0022%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4143565768
- Network
- In network
- Rendering NPI
- 4135577631
- Location
- Phoenix, AZ · TIN 51-1868485
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $68.00 | $42.16 | — | — | Review |
| Totals | $68.00 | $42.16 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- Patient account
- PA-526115
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-037019 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-15: OPTIONS-PPO (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-030707; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Diabetes Center (4143565768). | |
| 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 Diabetes Center2026-06-15 11:20
Established patient presents with thyrotoxicosis, unspecified; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-07-16 02:36
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-030707.pdf1 page
Provider cover letter requesting replacement of CLM-2026-030707.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-030707; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026460 | 2026-07-01 | Meadow Physical Therapy | $547.00 | Approved |
| CLM-2026-030707 | 2026-06-15 | Desert Diabetes Center | $68.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.