CLM-2026-002418
Mesa Medical Group, Internal Medicine. Service 2025-10-25 at office (POS 11). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Brittany Stephens
- Member ID
- UHC-39290-82
- Date of birth
- 1945-01-14
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411096
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5867
- Coverage period
- 2023-11-01 to present
- Deductible
- $1,211.54 of $3,500.0035%
- Out-of-pocket maximum
- $1,926.76 of $10,500.0018%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9057332212
- Network
- In network
- Rendering NPI
- 1272374640
- Location
- San Diego, CA · TIN 98-1862745
- Authorisation / referral
- none / REF849755
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $273.00 | $169.26 | — | — | DeniedCO29 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $76.00 | $47.12 | — | — | DeniedCO29 |
| 3 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 2 | $389.00 | $241.18 | — | — | DeniedCO29 |
| Totals | $738.00 | $457.56 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-233048
- 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-015977 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-25: NAVIGATE-HMO (HMO), effective 2023-11-01. | |
| Timely filing | Fail | CO29 | Received 210 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 Medical Group (9057332212). | |
| 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 Medical Group2025-10-25 18:43
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-23 00:54
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 210 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003601 | 2026-01-17 | Harbor Medical Group | $285.00 | 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.