CLM-2026-002001
Mesa Internal Medicine Associates, Internal Medicine. Service 2025-10-12 at office (POS 11). Received 2026-01-22.
Member
Resolved through the identity graph
- Member
- Richard Luna
- Member ID
- UHC-69234-20
- Date of birth
- 1986-01-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-403238
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0203
- Coverage period
- 2021-01-01 to present
- Deductible
- $128.85 of $1,000.0013%
- Out-of-pocket maximum
- $1,443.52 of $3,000.0048%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 7667531934
- Network
- Out of network
- Rendering NPI
- 4023910399
- Location
- Miami, FL · TIN 27-5098805
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $77.00 | $34.65 | — | — | DeniedCO29 |
| Totals | $77.00 | $34.65 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-159689
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006585 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-12: NULL (PPO), effective 2021-01-01. | |
| Timely filing | Fail | CO29 | Received 102 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Associates2025-10-12 15:43
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-22 06:31
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
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 102 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002303 | 2026-05-19 | Unity Bone and Joint Center | $2,374.00 | Approved |
| CLM-2026-005252 | 2026-01-21 | Northgate Medical Group | $244.00 | Approved |
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.