CLM-2026-006087
Mesa Medical Group, Family Medicine. Service 2026-09-08 at office (POS 11). Received 2026-10-08.
Member
Resolved through the identity graph
- Member
- Cynthia Flores
- Member ID
- UHC-94639-58
- Date of birth
- 1954-12-28
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-417547
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1980
- Coverage period
- 2025-12-01 to 2026-05-06
- Deductible
- $422.37 of $500.0084%
- Out-of-pocket maximum
- $506.54 of $1,500.0034%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7662849547
- Network
- In network
- Rendering NPI
- 5908673887
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $253.00 | $156.86 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 2 | $145.00 | $89.90 | — | — | DeniedCO27 |
| Totals | $398.00 | $246.76 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-942232
- 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-041462 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-08 is after coverage terminated on 2026-05-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 30 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Medical Group2026-09-08 18:00
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-08 06:12
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 2026-09-08 is after coverage terminated on 2026-05-06.
Other claims for this member
Same resolved identity
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.