CLM-2026-004176
Mesa Behavioral Health, Behavioral Health. Service 2026-08-28 at telehealth (POS 02). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Wayne Coleman
- Member ID
- UHC-27015-08
- Date of birth
- 1961-12-22
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-402898
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1843
- Coverage period
- 2021-11-01 to 2026-06-17
- Deductible
- $203.39 of $500.0041%
- Out-of-pocket maximum
- $255.89 of $1,000.0026%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 7796147859
- Network
- In network
- Rendering NPI
- 7164305261
- Location
- Nashville, TN · TIN 40-4103519
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $238.00 | $147.56 | — | — | DeniedCO27 |
| Totals | $238.00 | $147.56 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- Patient account
- PA-982425
- 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-023267 (verified, link confidence 0.93). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-28 is after coverage terminated on 2026-06-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 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 Behavioral Health (7796147859). | |
| 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 Behavioral Health2026-08-28 11:59
Patient seen for generalized anxiety disorder.
- SystemSystem: Claims system2026-09-17 02:55
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-17 13:37
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 13:43Eligibility: Date of service 2026-08-28 is after coverage terminated on 2026-06-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033872 | 2026-07-23 | Sunrise Internal Medicine Associates | $190.00 | 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.