CLM-2026-010965
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-03-08 at office (POS 11). Received 2026-04-02.
Member
Resolved through the identity graph
- Member
- Luis Sullivan
- Member ID
- UHC-55732-71
- Date of birth
- 1950-06-03
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-409633
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5248
- Coverage period
- 2023-08-01 to present
- Deductible
- $2,222.41 of $3,500.0063%
- Out-of-pocket maximum
- $2,137.80 of $14,000.0015%
- Copays
- office $20.00, specialist $75.00, 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
- 9825984104
- Location
- Los Angeles, CA · TIN 98-0064995
- Authorisation / referral
- none / REF930215
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 | $75.00 | $46.50 | $20.00 | $26.50 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $67.00 | $41.54 | $0.00 | $41.54 | Paid |
| Totals | $142.00 | $88.04 | $20.00 | $68.04 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-487904
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004563 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-08: CORE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 25 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 Associates2026-03-08 10:59
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.