CLM-2026-000147
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-03-18 at office (POS 11). Received 2026-09-22.
Member
Resolved through the identity graph
- Member
- Camila Rios
- Member ID
- UHC-12493-59
- Date of birth
- 1963-11-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-429149
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1346
- Coverage period
- 2024-01-01 to present
- Deductible
- $813.93 of $1,000.0081%
- Out-of-pocket maximum
- $889.76 of $2,000.0044%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9577388835
- Network
- In network
- Rendering NPI
- 2362956825
- Location
- San Diego, CA · TIN 59-7978167
- Authorisation / referral
- none / REF160319
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 | $79.00 | $48.98 | — | — | DeniedCO29 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $292.00 | $181.04 | — | — | DeniedCO29 |
| Totals | $371.00 | $230.02 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. J44.9 COPD, unspecified
- Patient account
- PA-775418
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-002324 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-18: CORE-HMO (HMO), effective 2024-01-01. | |
| Timely filing | Fail | CO29 | Received 188 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Internal Medicine Associates (9577388835). | |
| 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: Mesa Internal Medicine Associates2026-03-18 13:26
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-22 04:46
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-22 10:47
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 188 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032646 | 2025-12-13 | Mesa Bone and Joint Center | $3,864.00 | Needs review |
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
Received after the timely-filing limit.