CLM-2026-010627
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-06-30 at office (POS 11). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Lauren Taylor
- Member ID
- UHC-85275-26
- Date of birth
- 1984-08-28
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-405993
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8519
- Coverage period
- 2024-04-01 to 2026-03-14
- Deductible
- $1,455.94 of $2,500.0058%
- Out-of-pocket maximum
- $551.51 of $10,000.006%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4707375216
- Network
- In network
- Rendering NPI
- 7458167575
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $104.00 | $64.48 | — | — | DeniedCO27 |
| Totals | $104.00 | $64.48 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. J44.9 COPD, unspecified
- Patient account
- PA-547294
- 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-012308 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-30 is after coverage terminated on 2026-03-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Internal Medicine Associates2026-06-30 12:10
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-23 01:12
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-30 is after coverage terminated on 2026-03-14.
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
Service after coverage termination.