CLM-2026-005765
Mesa Family Practice, Family Medicine. Service 2025-10-20 at office (POS 11). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Martha Jenkins
- Member ID
- UHC-38108-73
- Date of birth
- 1987-01-15
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-426991
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5107
- Coverage period
- 2023-09-01 to present
- Deductible
- $215.13 of $500.0043%
- Out-of-pocket maximum
- $151.36 of $1,000.0015%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 8756169537
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $226.00 | $140.12 | — | — | DeniedCO29 |
| 2 | 36415 | Venipuncture | 25 | 1 | 1,2 | $25.00 | $15.50 | — | — | DeniedCO29 |
| Totals | $251.00 | $155.62 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-133030
- 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-005073 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-10-20: CORE-HMO (HMO), effective 2023-09-01. | |
| Timely filing | Fail | CO29 | Received 210 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Practice2025-10-20 18:53
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-05-18 02:09
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-18 09:58
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 210 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003271 | 2025-12-10 | Desert Internal Medicine Associates | $289.00 | Needs review |
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
Received after the timely-filing limit.