CLM-2026-006935
Mesa Cardiovascular Associates, Cardiology. Service 2026-08-25 at office (POS 11). Received 2026-09-25.
Member
Resolved through the identity graph
- Member
- Juan Powell
- Member ID
- UHC-99289-88
- Date of birth
- 1975-01-22
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-408880
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7466
- Coverage period
- 2022-02-01 to present
- Deductible
- $2,604.28 of $3,500.0074%
- Out-of-pocket maximum
- $2,717.49 of $10,500.0026%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4876629211
- Network
- In network
- Rendering NPI
- 2754598144
- Location
- Austin, TX · TIN 24-4510825
- 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 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $464.00 | $287.68 | — | — | DeniedCO18 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $335.00 | $207.70 | — | — | DeniedCO18 |
| Totals | $799.00 | $495.38 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-404207
- 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-002683 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-25: CHOICE-PLUS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-006934: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Cardiovascular Associates (4876629211). | |
| 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 Cardiovascular Associates2026-08-25 16:52
Patient seen for heart failure, unspecified.
- SystemSystem: Claims system2026-09-25 02:17
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-006934: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006934 | 2026-08-25 | Mesa Cardiovascular Associates | $799.00 | Approved |
| CLM-2026-016604 | 2026-02-15 | Lakeside Bone and Joint Center | $237.00 | Approved |
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
Exact duplicate of an earlier submission.