Professional claim · CMS-1500 · Provider portal
CLM-2026-015154
Mesa Diabetes Center, Endocrinology. Service 2026-01-27 at office (POS 11). Received 2026-02-01.
Denied
Billed
$515.00
2 lines
Allowed
$319.30
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Gary Palmer
- Member ID
- UHC-85894-33
- Date of birth
- 1948-08-24
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-403255
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8943
- Coverage period
- 2022-04-01 to 2026-01-07
- Deductible
- $178.16 of $500.0036%
- Out-of-pocket maximum
- $290.07 of $1,000.0029%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 2446853584
- Network
- In network
- Rendering NPI
- 2050665621
- Location
- Denver, CO · TIN 89-4122070
- Authorisation / referral
- none / REF684660
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $310.00 | $192.20 | — | — | DeniedCO27 |
| 2 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $205.00 | $127.10 | — | — | DeniedCO27 |
| Totals | $515.00 | $319.30 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
Claim header
- Patient account
- PA-982254
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-009538 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-01-27 is after coverage terminated on 2026-01-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 Diabetes Center (2446853584). | |
| 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. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Diabetes Center2026-01-27 16:17
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-02-01 04:52
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-01-27 is after coverage terminated on 2026-01-07.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019538 | 2026-02-26 | Mesa Regional Medical Center | $2,215.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied 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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.