CLM-2026-016232
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-03-09 at office (POS 11). Received 2026-04-12.
Member
Resolved through the identity graph
- Member
- Frances Pierce
- Member ID
- UHC-15944-44
- Date of birth
- 1938-06-09
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-402605
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6826
- Coverage period
- 2022-12-01 to present
- Deductible
- $102.37 of $1,000.0010%
- Out-of-pocket maximum
- $690.87 of $3,000.0023%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 7667531934
- Network
- Out of network
- Rendering NPI
- 7714355162
- Location
- Miami, FL · TIN 27-5098805
- 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 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1 | $360.00 | $162.00 | — | — | DeniedCO204 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 2 | $299.00 | $134.55 | — | — | DeniedCO204 |
| Totals | $659.00 | $296.55 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-929563
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010936 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-09: SELECT-EPO (EPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 34 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 | Fail | CO204 | Billing provider 7667531934 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-03-09 14:52
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-04-12 05:09
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-12 10:08
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 7667531934 is out of network and the EPO plan has no out-of-network benefit. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.