CLM-2026-013345
Mesa Family Practice, Family Medicine. Service 2026-06-12 at office (POS 11). Received 2026-06-18.
Member
Resolved through the identity graph
- Member
- Lori Franklin
- Member ID
- UHC-98775-39
- Date of birth
- 1982-04-15
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-428680
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-0309
- Coverage period
- 2021-05-01 to 2026-07-27
- Deductible
- $310.37 of $500.0062%
- Out-of-pocket maximum
- $893.06 of $2,000.0045%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3505890145
- Network
- In network
- Rendering NPI
- 5071054790
- Location
- Atlanta, GA · TIN 15-9233501
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $166.00 | $102.92 | $25.00 | $77.92 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $32.00 | $19.84 | $0.00 | $19.84 | Paid |
| 3 | 36415 | Venipuncture | — | 1 | 1 | $16.00 | $9.92 | $0.00 | $9.92 | Paid |
| Totals | $214.00 | $132.68 | $25.00 | $107.68 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-612319
- 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-018271 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-06-12: NULL (PPO), effective 2021-05-01, terms 2026-07-27. | |
| Timely filing | Pass | Received 6 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 (3505890145). | |
| 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 Family Practice2026-06-12 09:12
Patient seen for low back pain, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-18 04:16
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-612319.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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014344 | 2025-08-29 | Lakeside Skin Care Associates | $799.00 | Denied |
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.