CLM-2026-000974
Mesa Family Practice, Family Medicine. Service 2026-01-09 at office (POS 11). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Dylan Day
- Member ID
- UHC-32420-88
- Date of birth
- 1946-11-15
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428123
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9281
- Coverage period
- 2025-05-01 to present
- Deductible
- $1,928.99 of $3,500.0055%
- Out-of-pocket maximum
- $2,470.51 of $10,500.0024%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9198076652
- Network
- In network
- Rendering NPI
- 3392697793
- Location
- Denver, CO · TIN 38-9829181
- 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 | 36415 | Venipuncture | — | 1 | 1 | $22.00 | $13.64 | — | — | Review |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 1 | $295.00 | $182.90 | — | — | Review |
| Totals | $317.00 | $196.54 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-430009
- 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-013860 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-09: CORE-HMO (HMO), effective 2025-05-01. | |
| Timely filing | Pass | Received 58 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-000973, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Family Practice (9198076652). | |
| 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 Family Practice2026-01-09 13:13
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-03-08 04:10
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-08 12:38
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-000973, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000973 | 2026-01-09 | Meadow Family Practice | $317.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.