CLM-2026-015083
Mesa Internal Medicine Associates, Internal Medicine. Service 2025-12-05 at office (POS 11). Received 2026-01-03.
Member
Resolved through the identity graph
- Member
- Stephen Lewis
- Member ID
- UHC-79108-37
- Date of birth
- 1945-04-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-423267
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4585
- Coverage period
- 2024-12-01 to present
- Deductible
- $938.12 of $1,500.0063%
- Out-of-pocket maximum
- $2,023.07 of $4,500.0045%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4707375216
- Network
- In network
- Rendering NPI
- 2155982814
- 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 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $264.00 | $163.68 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1,2 | $299.00 | $185.38 | — | — | Review |
| Totals | $563.00 | $349.06 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-355910
- 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-000785 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-05: CHOICE-PLUS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 29 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Associates2025-12-05 11:16
Patient seen for essential (primary) hypertension. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-03 03:43
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-355910.pdf7 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-22 12:49The claim is for an office visit with a member who is eligible and in coverage. The provider is in-network, and the service is medically necessary. The use of modifier 59 is justified by the clinical note and operative note, which document procedures at distinct anatomical sites. The claim is within the auto-adjudication ceiling and does not require prior authorization. All required documentation is present, and there are no benefit limits or duplicate issues.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 406b72af
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:49 · 9e375b71
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031456 | 2026-05-12 | Desert Rehabilitation Center | $321.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an office visit with a member who is eligible and in coverage. The provider is in-network, and the service is medically necessary. The use of modifier 59 is justified by the clinical note and operative note, which document procedures at distinct anatomical sites. The claim is within the auto-adjudication ceiling and does not require prior authorization. All required documentation is present, and there are no benefit limits or duplicate issues.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.