CLM-2026-032352
Desert Medical Group, Internal Medicine. Service 2026-07-11 to 2026-07-12 at inpatient hospital (POS 21). Received 2026-07-28.
Member
Resolved through the identity graph
- Member
- Anthony Kelly
- Member ID
- UHC-84357-74
- Date of birth
- 2000-12-23
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-400683
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4330
- Coverage period
- 2023-02-01 to present
- Deductible
- $587.47 of $1,000.0059%
- Out-of-pocket maximum
- $623.77 of $3,000.0021%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- 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
- 3110917440
- Location
- Atlanta, GA · TIN 67-2719316
- Authorisation / referral
- none / REF267049
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 | $219.00 | $120.45 | $120.45 | $0.00 | Paid |
| Totals | $219.00 | $120.45 | $120.45 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-642011
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-11 to 2026-07-12
- 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-003081 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-11: CORE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 16 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 Group2026-07-12 14:46
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
- Itemized billitemized_PA-642011.pdf7 pages
Itemised statement totalling $219.00 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-2026-003258 | 2026-04-16 | Harbor Regional Medical Center | $4,250.00 | 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.