Professional claim · CMS-1500 · Paper
CLM-2026-005981
Mesa Medical Group, Family Medicine. Service 2026-03-15 at office (POS 11). Received 2026-04-27.
Approved
Billed
$243.00
2 lines
Allowed
$150.66
contract rate applied
Plan pays
$110.66
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Kyle Vega
- Member ID
- UHC-33957-43
- Date of birth
- 1943-01-08
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-408620
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0751
- Coverage period
- 2023-07-01 to present
- Deductible
- $2,534.32 of $3,500.0072%
- Out-of-pocket maximum
- $321.27 of $7,000.005%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7662849547
- Network
- In network
- Rendering NPI
- 1032620548
- Location
- Los Angeles, CA · TIN 30-7296562
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $208.00 | $128.96 | $40.00 | $88.96 | Paid |
| 2 | 90471 | Immunization administration | 25 | 1 | 1 | $35.00 | $21.70 | $0.00 | $21.70 | Paid |
| Totals | $243.00 | $150.66 | $40.00 | $110.66 | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-810862
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011634 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-15: CHOICE-PLUS-PPO (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 43 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 Medical Group (7662849547). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Medical Group2026-03-15 15:52
Patient seen for acute upper respiratory infection, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$243.00
Plan discount
$92.34
contracted rate
Plan paid
$110.66
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026798 | 2026-06-14 | Summit Imaging Center | $3,563.00 | Needs review |
| CLM-2026-003565 | 2026-06-11 | Mesa Family Practice | $457.00 | Approved |
| CLM-2026-024728 | 2026-02-06 | Evergreen Primary Care Associates | $229.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.