CLM-2026-015128
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-03-10 to 2026-03-13 at inpatient hospital (POS 21). Received 2026-03-25.
Member
Resolved through the identity graph
- Member
- Emily Wallace
- Member ID
- UHC-48730-84
- Date of birth
- 2004-10-05
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-413655
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9508
- Coverage period
- 2023-05-01 to 2026-03-10
- Deductible
- $97.73 of $1,000.0010%
- Out-of-pocket maximum
- $203.05 of $3,000.007%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1153640218
- Network
- In network
- Rendering NPI
- 8812304797
- Location
- Houston, TX · TIN 60-7207391
- Authorisation / referral
- none / REF246189
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 | $177.00 | $97.35 | $97.35 | $0.00 | Paid |
| Totals | $177.00 | $97.35 | $97.35 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-480526
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-10 to 2026-03-11
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013014 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-10: CORE-HMO (HMO), effective 2023-05-01, terms 2026-03-10. | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Internal Medicine Associates2026-03-13 13:17
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-03-25 03:01
Attachments
Documents received with the claim
- Itemized billitemized_PA-480526.pdf7 pages
Itemised statement totalling $177.00 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 12:44Clean claim.
Other claims for this member
Same resolved identity
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
Service after coverage termination.