CLM-2026-008434
Mesa Family Practice, Family Medicine. Service 2026-04-13 at office (POS 11). Received 2026-07-28.
Member
Resolved through the identity graph
- Member
- Charlotte Henderson
- Member ID
- UHC-48982-35
- Date of birth
- 1977-12-06
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-402752
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-3670
- Coverage period
- 2022-09-01 to 2026-08-20
- Deductible
- $1,188.93 of $2,500.0048%
- Out-of-pocket maximum
- $3,331.56 of $7,500.0044%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9198076652
- Network
- In network
- Rendering NPI
- 2357304296
- Location
- Denver, CO · TIN 38-9829181
- 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 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $263.00 | $163.06 | — | — | DeniedCO29 |
| Totals | $552.00 | $342.24 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-472866
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-039156 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-13: N/A (PPO), effective 2022-09-01, terms 2026-08-20. | |
| Timely filing | Fail | CO29 | Received 106 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 Family Practice (9198076652). | |
| 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 Family Practice2026-04-13 13:16
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-07-28 04:23
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 106 days after the last date of service (limit 90).
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
Received after the timely-filing limit.