CLM-2026-002604
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-09-19 at office (POS 11). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Bradley Oliver
- Member ID
- UHC-67161-27
- Date of birth
- 1951-09-07
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-415180
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2486
- Coverage period
- 2021-06-01 to present
- Deductible
- $737.68 of $1,000.0074%
- Out-of-pocket maximum
- $145.29 of $3,000.005%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4707375216
- Network
- In network
- Rendering NPI
- 9835118537
- Location
- Los Angeles, CA · TIN 98-0064995
- Authorisation / referral
- none / REF149168
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 | $391.00 | $242.42 | $40.00 | $202.42 | Paid |
| Totals | $391.00 | $242.42 | $40.00 | $202.42 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-829423
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003365 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-19: NAVIGATE-HMO (HMO), effective 2021-06-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| 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 (4707375216). | |
| 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 Associates2026-09-19 12:17
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002605 | 2026-09-19 | Mesa Internal Medicine Associates | $391.00 | Needs review |
| CLM-2026-033410 | 2026-05-29 | Canyon Clinical Laboratories | $87.00 | Needs review |
| CLM-2026-033409 | 2026-05-29 | Canyon Clinical Laboratories | $87.00 | Approved |
| CLM-2026-023388 | 2026-03-13 | Pinecrest Medical Group | $166.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.