Professional claim · CMS-1500 · EDI 837P
CLM-2026-010928
Mesa Family Practice, Family Medicine. Service 2026-07-09 at office (POS 11). Received 2026-08-18.
Denied
Billed
$431.00
2 lines
Allowed
$267.22
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Patricia Marshall
- Member ID
- UHC-92316-19
- Date of birth
- 1981-06-08
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-422996
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1390
- Coverage period
- 2022-10-01 to 2026-01-26
- Deductible
- $2,891.10 of $3,500.0083%
- Out-of-pocket maximum
- $2,827.87 of $10,500.0027%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 6155424479
- Location
- San Diego, CA · TIN 89-4780194
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $210.00 | $130.20 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $221.00 | $137.02 | — | — | DeniedCO27 |
| Totals | $431.00 | $267.22 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-951927
- 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-006322 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-09 is after coverage terminated on 2026-01-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 40 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 Family Practice (7652159394). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Family Practice2026-07-09 14:20
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-08-18 00:39
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-18 10:01
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-09 is after coverage terminated on 2026-01-26.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031425 | 2026-06-03 | Meadow Regional Medical Center | $1,102.00 | Denied |
| CLM-2026-020532 | 2026-03-16 | Meadow Primary Care Associates | $176.00 | Denied |
| CLM-2026-005832 | 2026-02-03 | Unity Reference Lab | $180.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.