CLM-2026-013490
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-07-10 to 2026-07-12 at inpatient hospital (POS 21). Received 2026-07-25.
Member
Resolved through the identity graph
- Member
- Tyler Rojas
- Member ID
- none on golden record
- Date of birth
- 1966-04-24
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-411428
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- UNKNOWN PPO group NULL
- Coverage period
- 2023-06-01 to present
- Deductible
- $655.65 of $1,000.0066%
- Out-of-pocket maximum
- $1,136.49 of $3,000.0038%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1153640218
- Network
- In network
- Rendering NPI
- 4975096940
- Location
- Houston, TX · TIN 60-7207391
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $190.00 | $104.50 | $104.50 | $0.00 | Paid |
| Totals | $190.00 | $104.50 | $104.50 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-963408
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-10 to 2026-07-14
- 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-039562 (verified, link confidence 0.97). | |
| Eligibility | Note | Active on 2026-07-10: UNKNOWN (PPO), effective 2023-06-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 13 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 (1153640218). | |
| 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 Associates2026-07-12 18:27
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-963408.pdf9 pages
Itemised statement totalling $190.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Eligibility: Active on 2026-07-10: UNKNOWN (PPO), effective 2023-06-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025308 | 2026-08-09 | Riverside Regional Medical Center | $2,707.00 | 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.