CLM-2026-006667
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-05-24 at office (POS 11). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Gregory Le
- Member ID
- none on golden record
- Date of birth
- 1939-12-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422772
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-0662
- Coverage period
- 2024-01-01 to present
- Deductible
- $855.88 of $2,500.0034%
- Out-of-pocket maximum
- $1,503.99 of $5,000.0030%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4707375216
- Network
- In network
- Rendering NPI
- 5004891649
- Location
- Los Angeles, CA · TIN 98-0064995
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $68.00 | $42.16 | — | — | PendedIDQ |
| 2 | 99215 | Office visit, established patient, high complexity | 25 | 1 | 1 | $369.00 | $228.78 | — | — | PendedIDQ |
| Totals | $437.00 | $270.94 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-568006
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000151; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-24: OPTIONS-PPO (PPO), effective 2024-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 45 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 Internal Medicine Associates (4707375216). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications rec”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Internal Medicine Associates2026-05-24 12:20
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-08 03:26
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-08 13:43
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 enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000151; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-24: OPTIONS-PPO (PPO), effective 2024-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. Completeness: Documentation incomplete: “Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications rec”.
Other claims for this member
Same resolved identity
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
Development letter outstanding.