CLM-2026-033173
Desert Medical Group, Internal Medicine. Service 2026-05-06 to 2026-05-07 at inpatient hospital (POS 21). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Ronald Lee
- Member ID
- UHC-48449-29
- Date of birth
- 1941-06-28
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-415928
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7294
- Coverage period
- 2024-10-01 to 2026-03-24
- Deductible
- $46.20 of $1,000.005%
- Out-of-pocket maximum
- $640.56 of $4,000.0016%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4556045621
- Network
- In network
- Rendering NPI
- 7565952133
- Location
- Scottsdale, AZ · TIN 56-2756422
- 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 | $232.00 | $127.60 | — | — | DeniedCO27 |
| Totals | $232.00 | $127.60 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-162844
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-06 to 2026-05-08
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014245 (verified, link confidence 0.93). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-06 is after coverage terminated on 2026-03-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 44 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 (4556045621). | |
| 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 Group2026-05-07 11:45
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-06-20 03:45
Attachments
Documents received with the claim
- Itemized billitemized_PA-162844.pdf6 pages
Itemised statement totalling $232.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-06 is after coverage terminated on 2026-03-24.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007325 | 2026-07-13 | Lakeside Reference Lab | $107.00 | Denied |
| CLM-2026-020978 | 2026-06-23 | Mesa Medical Group | $306.00 | Denied |
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
Service after coverage termination.