Professional claim · CMS-1500 · Provider portal
CLM-2026-013088
Mesa Diabetes Center, Endocrinology. Service 2026-05-13 at office (POS 11). Received 2026-06-09.
Denied
Billed
$758.00
2 lines
Allowed
$469.96
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Randy Riley
- Member ID
- UHC-06936-55
- Date of birth
- 1975-07-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432716
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group NULL
- Coverage period
- 2025-10-01 to 2026-03-12
- Deductible
- $1,341.04 of $3,500.0038%
- Out-of-pocket maximum
- $1,382.46 of $14,000.0010%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 3634244123
- Network
- In network
- Rendering NPI
- 3523772234
- Location
- Scottsdale, AZ · TIN 19-2073831
- 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 | $328.00 | $203.36 | — | — | DeniedCO27 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $430.00 | $266.60 | — | — | DeniedCO27 |
| Totals | $758.00 | $469.96 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
Claim header
- Patient account
- PA-120442
- 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-032268 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-13 is after coverage terminated on 2026-03-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 27 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 Diabetes Center (3634244123). | |
| 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 Diabetes Center2026-05-13 18:09
Patient seen for hypothyroidism, unspecified.
- SystemSystem: Claims system2026-06-09 00:43
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 2026-05-13 is after coverage terminated on 2026-03-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023653 | 2026-04-12 | Sunrise Cardiovascular Associates | $332.00 | 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.