CLM-2026-002992
Mesa Internal Medicine Associates, Internal Medicine. Service 2025-12-12 at office (POS 11). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Elijah Shaw
- Member ID
- UHC-98614-28
- Date of birth
- 1988-05-16
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-423424
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7323
- Coverage period
- 2023-12-01 to present
- Deductible
- $505.83 of $1,000.0051%
- Out-of-pocket maximum
- $1,449.60 of $3,000.0048%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 7667531934
- Network
- Out of network
- Rendering NPI
- 3854643822
- Location
- Miami, FL · TIN 27-5098805
- Authorisation / referral
- none / REF866604
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 | $63.00 | $28.35 | — | — | DeniedCO204 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $349.00 | $157.05 | — | — | DeniedCO204 |
| Totals | $412.00 | $185.40 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-522328
- 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-005135 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-12: NAVIGATE-HMO (HMO), effective 2023-12-01. | |
| Timely filing | Pass | Received 36 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 | Fail | CO204 | Billing provider 7667531934 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2025-12-12 11:38
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-17 05:53
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-17 08:31
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 7667531934 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.