CLM-2026-013482
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-03-25 at office (POS 11). Received 2026-04-09.
Member
Resolved through the identity graph
- Member
- Patrick Ortega
- Member ID
- UHC-45462-68
- Date of birth
- 2001-07-20
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-422226
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5629
- Coverage period
- 2024-12-01 to present
- Deductible
- $427.12 of $500.0085%
- Out-of-pocket maximum
- $581.50 of $1,500.0039%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4707375216
- Network
- In network
- Rendering NPI
- 8836155621
- Location
- Los Angeles, CA · TIN 98-0064995
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $72.00 | $44.64 | $40.00 | $4.64 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $74.00 | $45.88 | $0.00 | $45.88 | Paid |
| Totals | $146.00 | $90.52 | $40.00 | $50.52 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-695646
- 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-006550 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-25: CHOICE-PLUS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 15 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 Internal Medicine Associates (4707375216). | |
| 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 Associates2026-03-25 15:31
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
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-2026-004863 | 2026-06-08 | Sunrise Physical Therapy | $118.00 | Approved |
| CLM-2026-005687 | 2026-02-04 | Unity Community Hospital | $1,308.00 | Approved |
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
Clean claim, priced at contract rate.