Professional claim · CMS-1500 · EDI 837P
CLM-2026-033576
Desert Medical Group, Internal Medicine. Service 2026-03-18 at office (POS 11). Received 2026-04-18.
Denied
Billed
$292.00
1 line
Allowed
$181.04
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Karen Rogers
- Member ID
- UHC-25867-04
- Date of birth
- 1981-07-19
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-401512
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8233
- Coverage period
- 2025-05-01 to 2026-01-15
- Deductible
- $151.86 of $1,500.0010%
- Out-of-pocket maximum
- $827.84 of $3,000.0028%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5303428622
- Network
- In network
- Rendering NPI
- 1471219406
- Location
- Atlanta, GA · TIN 67-2719316
- Authorisation / referral
- none / none
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $292.00 | $181.04 | — | — | DeniedCO27 |
| Totals | $292.00 | $181.04 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-175525
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026487 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-18 is after coverage terminated on 2026-01-15. Expenses incurred after coverage terminated |
| 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 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Medical Group2026-03-18 18:27
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-04-18 03:09
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-18 is after coverage terminated on 2026-01-15.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.