CLM-2026-004089
Mesa Family Practice, Family Medicine. Service 2026-07-26 at office (POS 11). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Teresa Harrison
- Member ID
- UHC-43377-08
- Date of birth
- 1951-12-01
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-421161
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-6984
- Coverage period
- 2022-06-01 to 2026-07-18
- Deductible
- $1,110.75 of $1,500.0074%
- Out-of-pocket maximum
- $277.95 of $3,000.009%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3505890145
- Network
- In network
- Rendering NPI
- 1376950147
- Location
- Atlanta, GA · TIN 15-9233501
- 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 | $38.00 | $23.56 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $223.00 | $138.26 | — | — | DeniedCO27 |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $174.00 | $107.88 | — | — | DeniedCO27 |
| Totals | $435.00 | $269.70 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-157819
- 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-010702 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-26 is after coverage terminated on 2026-07-18. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 44 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 (3505890145). | |
| 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 Practice2026-07-26 16:09
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-08 03:39
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-08 14:59
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-26 is after coverage terminated on 2026-07-18.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008589 | 2026-07-20 | Unity Clinical Laboratories | $187.00 | 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.