CLM-2026-032883
Desert Internal Medicine Associates, Internal Medicine. Service 2026-02-23 to 2026-02-24 at inpatient hospital (POS 21). Received 2026-03-27.
Member
Resolved through the identity graph
- Member
- Jeremy Reyes
- Member ID
- UHC-87372-54
- Date of birth
- 1973-02-03
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-407925
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2281
- Coverage period
- 2025-03-01 to present
- Deductible
- $1,948.38 of $2,500.0078%
- Out-of-pocket maximum
- $1,869.80 of $7,500.0025%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5106489862
- Network
- In network
- Rendering NPI
- 6026718323
- Location
- Houston, TX · TIN 11-1256116
- Authorisation / referral
- none / none
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 | $242.00 | $133.10 | $133.10 | $0.00 | Paid |
| Totals | $242.00 | $133.10 | $133.10 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-959298
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-02-23 to 2026-02-26
- 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-003804 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-23: MEDICARE-ADV-A (MA), effective 2025-03-01. | |
| Timely filing | Pass | Received 31 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 (5106489862). | |
| 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 Associates2026-02-24 17:13
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-959298.pdf8 pages
Itemised statement totalling $242.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020797 | 2026-05-21 | Sunrise Medical Group | $287.00 | Approved |
| CLM-2026-016198 | 2026-01-29 | Riverside Regional Medical Center | $1,476.00 | Approved |
| CLM-2026-000822 | 2026-01-03 | Heritage Imaging Center | $2,311.00 | Needs review |
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.