CLM-2026-012156
Mesa Internal Medicine Associates, Internal Medicine. Service 2025-12-23 at office (POS 11). Received 2026-01-14.
Member
Resolved through the identity graph
- Member
- Evelyn Ramos
- Member ID
- UHC-70497-07
- Date of birth
- 1989-05-05
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-420348
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4998
- Coverage period
- 2023-07-01 to present
- Deductible
- $2,190.90 of $2,500.0088%
- Out-of-pocket maximum
- $2,632.79 of $7,500.0035%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 7667531934
- Network
- Out of network
- Rendering NPI
- 1073343349
- Location
- Miami, FL · TIN 27-5098805
- Authorisation / referral
- none / REF885627
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 | $87.00 | $39.15 | — | — | DeniedCO204 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $90.00 | $40.50 | — | — | DeniedCO204 |
| Totals | $177.00 | $79.65 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-108486
- 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-004230 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-12-23: CORE-HMO (HMO), effective 2023-07-01. | |
| Timely filing | Pass | Received 22 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 | Fail | CO204 | Billing provider 7667531934 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2025-12-23 18:06
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-14 02:01
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-14 13:19
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 7667531934 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034606 | 2026-09-25 | Evergreen Medical Group | $411.00 | Needs review |
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
No out-of-network benefit on this plan.