CLM-2026-031391
Desert Diabetes Center, Endocrinology. Service 2026-06-19 at office (POS 11). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Allen Marcus
- Member ID
- UHC-50145-65
- Date of birth
- 1984-07-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-432204
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group NULL
- Coverage period
- 2022-08-01 to 2026-08-21
- Deductible
- $544.43 of $2,500.0022%
- Out-of-pocket maximum
- $3,651.68 of $10,000.0037%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 4143565768
- Network
- In network
- Rendering NPI
- 2431159138
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $267.00 | $165.54 | — | — | DeniedCO18 |
| 2 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1,2 | $181.00 | $112.22 | — | — | DeniedCO18 |
| Totals | $448.00 | $277.76 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E03.9 Hypothyroidism, unspecified
- Patient account
- PA-688923
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040169 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-19: OPTIONS-PPO (PPO), effective 2022-08-01, terms 2026-08-21. | |
| Timely filing | Pass | Received 60 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-031390: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Center2026-06-19 13:59
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-18 00:09
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-18 09:20
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-031390: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031390 | 2026-06-19 | Desert Diabetes Center | $448.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.