CLM-2026-002326
Mesa Internal Medicine Associates, Internal Medicine. Service 2025-11-24 at office (POS 11). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Arthur Welch
- Member ID
- UHC-72478-18
- Date of birth
- 1989-04-13
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-429031
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-0815
- Coverage period
- 2021-03-01 to present
- Deductible
- $260.92 of $500.0052%
- Out-of-pocket maximum
- $471.68 of $1,000.0047%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1153640218
- Network
- In network
- Rendering NPI
- 1743039970
- Location
- Houston, TX · TIN 60-7207391
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $373.00 | $231.26 | — | — | DeniedCO29 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $46.00 | $28.52 | — | — | DeniedCO29 |
| Totals | $419.00 | $259.78 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-826102
- 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-007644 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-24: - (PPO), effective 2021-03-01. | |
| Timely filing | Fail | CO29 | Received 170 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 (1153640218). | |
| 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 Associates2025-11-24 14:37
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-13 02:49
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 engineDenied2026-10-22 12:44Timely filing: Received 170 days after the last date of service (limit 90).
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
Received after the timely-filing limit.