CLM-2026-032103
Desert Internal Medicine Associates, Internal Medicine. Service 2026-01-12 at office (POS 11). Received 2026-01-19.
Member
Resolved through the identity graph
- Member
- Bobby Guzman
- Member ID
- UHC-75753-62
- Date of birth
- 1994-02-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400765
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9264
- Coverage period
- 2022-07-01 to present
- Deductible
- $47.67 of $1,000.005%
- Out-of-pocket maximum
- $1,450.74 of $4,000.0036%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6778439607
- Network
- In network
- Rendering NPI
- 4212854713
- Location
- Mesa, AZ · TIN 70-7613029
- Authorisation / referral
- none / REF551507
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $373.00 | $231.26 | — | — | Review |
| Totals | $373.00 | $231.26 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-944054
- 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-004828 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-12: NAVIGATE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 7 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-2026-032102; 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 Internal Medicine Associates (6778439607). | |
| 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 Associates2026-01-12 18:58
Established patient presents with unspecified atrial fibrillation; 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 system2026-01-19 05:58
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-19 17:08
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-032102.pdf1 page
Provider cover letter requesting replacement of CLM-2026-032102.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-032102; the original must be voided when this adjudicates.
- AI recommendationApproved2026-10-23 19:19This is a replacement claim (frequency code 7) that corrects an earlier submission [N1]. The original claim CLM-2026-032102 has been approved [H1], and this claim is intended to replace it in full. The provider has documented the reason for the replacement, and the claim is within the auto-adjudication ceiling [R-high_dollar]. All other adjudication rules have passed, and the claim is complete [R-completeness]. The original claim must be voided when this one adjudicates [R-replacement].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:19 · a914a79a
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032102 | 2026-01-12 | Desert Internal Medicine Associates | $373.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
This is a replacement claim (frequency code 7) that corrects an earlier submission [N1]. The original claim CLM-2026-032102 has been approved [H1], and this claim is intended to replace it in full. The provider has documented the reason for the replacement, and the claim is within the auto-adjudication ceiling [R-high_dollar]. All other adjudication rules have passed, and the claim is complete [R-completeness]. The original claim must be voided when this one adjudicates [R-replacement].
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.