CLM-2026-012897
Mesa Behavioral Health, Behavioral Health. Service 2025-12-26 at telehealth (POS 02). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Juan Vegga
- Member ID
- UHC-78778-54
- Date of birth
- 1967-02-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400740
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-8214
- Coverage period
- 2025-09-01 to present
- Deductible
- $1,436.33 of $2,500.0057%
- Out-of-pocket maximum
- $2,308.80 of $5,000.0046%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 7796147859
- Network
- In network
- Rendering NPI
- 3057564601
- Location
- Nashville, TN · TIN 40-4103519
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $311.00 | $192.82 | $60.00 | $132.82 | Paid |
| Totals | $311.00 | $192.82 | $60.00 | $132.82 | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-446113
- 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-005518 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-26: N/A (PPO), effective 2025-09-01. | |
| 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 Behavioral Health (7796147859). | |
| 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 Behavioral Health2025-12-26 15:37
Patient seen for adhd, combined type. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-18 03:59
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-18 14:39
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-446113.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
Authorisation must be confirmed with UM before payment.