Professional claim · CMS-1500 · Provider portal
CLM-2026-013862
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-03-06 at office (POS 11). Received 2026-03-18.
Approved
Billed
$70.00
1 line
Allowed
$43.40
contract rate applied
Plan pays
$18.40
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Anna Knight
- Member ID
- UHC-17139-80
- Date of birth
- 1952-02-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-430269
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9750
- Coverage period
- 2025-02-01 to present
- Deductible
- $948.79 of $2,500.0038%
- Out-of-pocket maximum
- $3,262.65 of $10,000.0033%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1153640218
- Network
- In network
- Rendering NPI
- 2224241861
- Location
- Houston, TX · TIN 60-7207391
- 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 | $70.00 | $43.40 | $25.00 | $18.40 | Paid |
| Totals | $70.00 | $43.40 | $25.00 | $18.40 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
- Patient account
- PA-298119
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014216 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-06: SELECT-EPO (EPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 12 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Internal Medicine Associates2026-03-06 14:15
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$70.00
Plan discount
$26.60
contracted rate
Plan paid
$18.40
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033650 | 2026-09-06 | Northgate Cardiovascular Associates | $448.00 | Approved |
| CLM-2026-034212 | 2026-02-19 | Riverside Diagnostic Imaging | $2,212.00 | Needs review |
| CLM-2026-012036 | 2026-02-02 | Sunrise Imaging Center | $2,963.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved 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
Approvedscenario: Clean
Clean claim, priced at contract rate.