CLM-2026-005486
Mesa Primary Care Associates, Family Medicine. Service 2026-03-28 at office (POS 11). Received 2026-05-09.
Member
Resolved through the identity graph
- Member
- Raymond Collins
- Member ID
- UHC-04176-72
- Date of birth
- 1971-03-26
- Identity
- Verified6 records, confidence 0.94
- Claim record
- CLMCLM-423108
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7630
- Coverage period
- 2021-01-01 to present
- Deductible
- $347.11 of $500.0069%
- Out-of-pocket maximum
- $279.78 of $2,000.0014%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1256425335
- Network
- In network
- Rendering NPI
- 8240244540
- Location
- Nashville, TN · TIN 57-2751445
- 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 | 99395 | Preventive visit, 18-39 years | 59 | 1 | 1 | $289.00 | $179.18 | — | — | Review |
| 2 | 36415 | Venipuncture | 59 | 1 | 2 | $22.00 | $13.64 | — | — | Review |
| Totals | $311.00 | $192.82 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-705823
- 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-006062 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-03-28: MEDICARE-ADV-A (MA), effective 2021-01-01. | |
| Timely filing | Pass | Received 42 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 Primary Care Associates (1256425335). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Primary Care Associates2026-03-28 14:20
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-05-09 02:38
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-705823.pdf7 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017936 | 2026-01-20 | Meadow Primary Care Associates | $25.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.