CLM-2026-007545
Mesa Diabetes Center, Endocrinology. Service 2026-03-28 at office (POS 11). Received 2026-07-18.
Member
Resolved through the identity graph
- Member
- David Griffin
- Member ID
- UHC-59486-30
- Date of birth
- 1958-07-13
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-427716
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8582
- Coverage period
- 2024-11-01 to present
- Deductible
- $874.81 of $1,000.0087%
- Out-of-pocket maximum
- $818.72 of $4,000.0020%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 2446853584
- Network
- In network
- Rendering NPI
- 1476575620
- Location
- Denver, CO · TIN 89-4122070
- 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 | $289.00 | $179.18 | — | — | DeniedCO29 |
| Totals | $289.00 | $179.18 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E03.9 Hypothyroidism, unspecified
- Patient account
- PA-908416
- 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-026913 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-28: - (PPO), effective 2024-11-01. | |
| Timely filing | Fail | CO29 | Received 112 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 Diabetes Center (2446853584). | |
| 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 Diabetes Center2026-03-28 17:08
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-18 04:21
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-18 11:59
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 engineDenied2026-10-21 13:43Timely filing: Received 112 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012314 | 2026-08-10 | Mesa Internal Medicine Associates | $114.00 | Approved |
| CLM-2026-015097 | 2026-07-02 | Heritage Community Hospital | $956.00 | Approved |
| CLM-2026-019710 | 2026-03-08 | Canyon Medical Group | $193.00 | 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
Received after the timely-filing limit.