CLM-2026-003564
Mesa Family Practice, Family Medicine. Service 2026-05-28 at office (POS 11). Received 2026-06-19.
Member
Resolved through the identity graph
- Member
- Bradley Santiago
- Member ID
- UHC-26632-77
- Date of birth
- 1976-02-23
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-429749
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0916
- Coverage period
- 2024-02-01 to 2026-01-05
- Deductible
- $848.31 of $1,000.0085%
- Out-of-pocket maximum
- $697.81 of $2,000.0035%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 9347314582
- 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 | $36.00 | $22.32 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $298.00 | $184.76 | — | — | DeniedCO27 |
| Totals | $334.00 | $207.08 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-815147
- 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-035531 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-28 is after coverage terminated on 2026-01-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 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 Practice2026-05-28 16:11
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-19 01:40
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-28 is after coverage terminated on 2026-01-05.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001275 | 2026-07-05 | Unity Cardiovascular Associates | $1,673.00 | Denied |
| CLM-2026-033443 | 2026-06-07 | Pinecrest Cardiovascular Associates | $718.00 | Denied |
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
Service after coverage termination.