CLM-2026-002401
Mesa Family Practice, Family Medicine. Service 2025-09-20 at office (POS 11). Received 2026-04-02.
Member
Resolved through the identity graph
- Member
- Frances Harris
- Member ID
- UHC-24775-06
- Date of birth
- 2008-05-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-420534
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2003
- Coverage period
- 2022-03-01 to present
- Deductible
- $706.20 of $1,000.0071%
- Out-of-pocket maximum
- $561.57 of $3,000.0019%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 5424697618
- Location
- San Diego, CA · TIN 89-4780194
- 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 | 90471 | Immunization administration | — | 1 | 1 | $31.00 | $19.22 | — | — | DeniedCO29 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $184.00 | $114.08 | — | — | DeniedCO29 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $215.00 | $133.30 | — | — | DeniedCO29 |
| Totals | $430.00 | $266.60 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-306866
- 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-023561 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-09-20: SELECT-EPO (EPO), effective 2022-03-01. | |
| Timely filing | Fail | CO29 | Received 194 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 Family Practice (7652159394). | |
| 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 Practice2025-09-20 13:37
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-04-02 05:37
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 194 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.