CLM-2026-032580
Desert Internal Medicine Associates, Internal Medicine. Service 2025-12-27 at office (POS 11). Received 2026-01-13.
Member
Resolved through the identity graph
- Member
- Aaron Rojas
- Member ID
- UHC-10065-30
- Date of birth
- 1938-03-27
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-423602
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6329
- Coverage period
- 2021-05-01 to present
- Deductible
- $724.40 of $1,000.0072%
- Out-of-pocket maximum
- $1,488.91 of $4,000.0037%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 6778439607
- Network
- In network
- Rendering NPI
- 2292064336
- Location
- Mesa, AZ · TIN 70-7613029
- Authorisation / referral
- none / REF600792
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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $104.00 | $64.48 | $20.00 | $44.48 | Paid |
| Totals | $104.00 | $64.48 | $20.00 | $44.48 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-233756
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003902 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-12-27: NAVIGATE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 17 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 (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 Associates2025-12-27 13:18
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000609 | 2026-09-24 | Pinecrest Diagnostic Imaging | $2,469.00 | Needs review |
| CLM-2026-013771 | 2026-02-09 | Sunrise Internal Medicine Associates | $606.00 | 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.