CLM-2026-009925
Mesa Medical Group, Family Medicine. Service 2025-12-28 at office (POS 11). Received 2026-08-03.
Member
Resolved through the identity graph
- Member
- Robert Weber
- Member ID
- UHC-94741-69
- Date of birth
- 1982-03-12
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-407696
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6366
- Coverage period
- 2021-09-01 to present
- Deductible
- $117.15 of $1,000.0012%
- Out-of-pocket maximum
- $831.76 of $3,000.0028%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7662849547
- Network
- In network
- Rendering NPI
- 5853630817
- 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 | 90471 | Immunization administration | — | 1 | 1 | $41.00 | $25.42 | — | — | DeniedCO29 |
| Totals | $41.00 | $25.42 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-935573
- 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-003015 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-28: NULL (PPO), effective 2021-09-01. | |
| Timely filing | Fail | CO29 | Received 218 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 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 Group2025-12-28 11:41
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-08-03 00:29
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 engineDenied2026-10-21 13:43Timely filing: Received 218 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032751 | 2026-03-02 | Lakeside Medical Group | $287.00 | Approved |
| CLM-2026-034462 | 2026-02-18 | Canyon Medical Group | $577.00 | Needs review |
| CLM-2026-034461 | 2026-02-18 | Canyon Medical Group | $577.00 | 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.