CLM-2026-013770
Mesa Medical Group, Internal Medicine. Service 2026-09-08 to 2026-09-12 at inpatient hospital (POS 21). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Cheryl Gibson
- Member ID
- UHC-20991-85
- Date of birth
- 1999-05-15
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432495
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5206
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,162.10 of $1,500.0077%
- Out-of-pocket maximum
- $1,811.93 of $4,500.0040%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9057332212
- Network
- In network
- Rendering NPI
- 3494713951
- Location
- San Diego, CA · TIN 98-1862745
- Authorisation / referral
- none / REF678890
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 | $212.00 | $116.60 | — | — | DeniedCO18 |
| Totals | $212.00 | $116.60 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-470069
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-09-08 to 2026-09-10
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029211 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-08: NAVIGATE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-013769: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Medical Group (9057332212). | |
| 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 Medical Group2026-09-12 13:34
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-09-29 02:04
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-470069.pdf6 pages
Itemised statement totalling $212.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-013769: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007729 | 2026-08-28 | Lakeside Medical Group | $441.00 | Approved |
| CLM-2026-013769 | 2026-09-08 | Mesa Medical Group | $212.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.