CLM-2026-013989
Mesa Primary Care Associates, Family Medicine. Service 2026-05-10 at office (POS 11). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Joseph Berry
- Member ID
- UHC-73065-25
- Date of birth
- 1999-08-25
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426873
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7464
- Coverage period
- 2025-10-01 to 2026-02-04
- Deductible
- $1,340.73 of $1,500.0089%
- Out-of-pocket maximum
- $1,756.24 of $4,500.0039%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1256425335
- Network
- In network
- Rendering NPI
- 3739386803
- Location
- Nashville, TN · TIN 57-2751445
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $339.00 | $210.18 | — | — | DeniedCO27 |
| Totals | $339.00 | $210.18 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-582685
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-023363 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-10 is after coverage terminated on 2026-02-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 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 Primary Care Associates (1256425335). | |
| 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 Primary Care Associates2026-05-10 16:59
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-18 05:21
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-18 16:20
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-10 is after coverage terminated on 2026-02-04.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018016 | 2026-03-03 | Cornerstone Digestive Health Center | $4,722.00 | Denied |
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
Service after coverage termination.