CLM-2026-004170
Mesa Diabetes Center, Endocrinology. Service 2026-01-10 at office (POS 11). Received 2026-02-07.
Member
Resolved through the identity graph
- Member
- Beverly Ortega
- Member ID
- UHC-09931-26
- Date of birth
- 1950-07-16
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-429350
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2139
- Coverage period
- 2022-09-01 to present
- Deductible
- $856.09 of $1,000.0086%
- Out-of-pocket maximum
- $679.61 of $4,000.0017%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 2446853584
- Network
- In network
- Rendering NPI
- 9165038503
- Location
- Denver, CO · TIN 89-4122070
- 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 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $133.00 | $82.46 | — | — | DeniedCO18 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $45.00 | $27.90 | — | — | DeniedCO18 |
| Totals | $178.00 | $110.36 | — | — | ||||||
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- Patient account
- PA-778618
- 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-006529 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-10: CHOICE-PLUS-PPO (PPO), effective 2022-09-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-004169: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Diabetes Center (2446853584). | |
| 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 Diabetes Center2026-01-10 15:07
Patient seen for hypothyroidism, unspecified.
- SystemSystem: Claims system2026-02-07 01:36
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-07 14:08
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 12:44Duplicate check: Exact duplicate of CLM-2026-004169: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023728 | 2026-09-03 | Pinecrest Primary Care Associates | $178.00 | Approved |
| CLM-2026-004169 | 2026-01-10 | Mesa Diabetes Center | $178.00 | 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
Exact duplicate of an earlier submission.