Professional claim · CMS-1500 · EDI 837P
CLM-2026-011252
Mesa Family Practice, Family Medicine. Service 2026-07-18 at office (POS 11). Received 2026-08-28.
Denied
Billed
$238.00
2 lines
Allowed
$147.56
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Jonathan Turner
- Member ID
- UHC-89708-54
- Date of birth
- 1939-06-23
- Identity
- Verified4 records, confidence 0.90
- Claim record
- CLMCLM-404431
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1570
- Coverage period
- 2025-12-01 to 2026-01-28
- Deductible
- $1,063.56 of $1,500.0071%
- Out-of-pocket maximum
- $103.03 of $6,000.002%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7916099477
- Network
- In network
- Rendering NPI
- 9040666858
- Location
- Miami, FL · TIN 48-0020072
- 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 | 36415 | Venipuncture | — | 1 | 1 | $18.00 | $11.16 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $220.00 | $136.40 | — | — | DeniedCO27 |
| Totals | $238.00 | $147.56 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-791273
- 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-012906 (verified, link confidence 0.90). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-18 is after coverage terminated on 2026-01-28. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 41 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 (7916099477). | |
| 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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Family Practice2026-07-18 13:06
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-08-28 02:42
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-28 15:13
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-18 is after coverage terminated on 2026-01-28.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022463 | 2026-01-28 | Harbor Medical Group | $724.00 | Approved |
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.