CLM-2026-034478
Desert Medical Group, Internal Medicine. Service 2026-06-15 to 2026-06-16 at inpatient hospital (POS 21). Received 2026-06-30.
Member
Resolved through the identity graph
- Member
- Juan Morris
- Member ID
- UHC-99012-31
- Date of birth
- 2008-10-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424138
- Relationship
- Child, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4029
- Coverage period
- 2021-10-01 to 2026-02-22
- Deductible
- $569.08 of $1,000.0057%
- Out-of-pocket maximum
- $84.43 of $2,000.004%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3427053921
- Network
- In network
- Rendering NPI
- 8904706511
- Location
- San Diego, CA · TIN 22-6599572
- 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 | $174.00 | $95.70 | — | — | DeniedCO27 |
| Totals | $174.00 | $95.70 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-232157
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-15 to 2026-06-18
- 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-036820 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-15 is after coverage terminated on 2026-02-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 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 (3427053921). | |
| 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 Group2026-06-16 15:52
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-30 02:27
Attachments
Documents received with the claim
- Itemized billitemized_PA-232157.pdf3 pages
Itemised statement totalling $174.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-15 is after coverage terminated on 2026-02-22.
Other claims for this member
Same resolved identity
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.