CLM-2026-017199
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-05-03 to 2026-05-06 at inpatient hospital (POS 21). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Carl Gibson
- Member ID
- UHC-12791-74
- Date of birth
- 1986-02-04
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-429141
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6173
- Coverage period
- 2022-03-01 to present
- Deductible
- $358.02 of $1,500.0024%
- Out-of-pocket maximum
- $1,227.21 of $6,000.0020%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9577388835
- Network
- In network
- Rendering NPI
- 3345913321
- Location
- San Diego, CA · TIN 59-7978167
- Authorisation / referral
- none / none
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 | $256.00 | $140.80 | $140.80 | $0.00 | Paid |
| Totals | $256.00 | $140.80 | $140.80 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-755395
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-03 to 2026-05-07
- 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-030938 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-03: MEDICARE-ADV-A (MA), effective 2022-03-01. | |
| Timely filing | Pass | Received 26 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 (9577388835). | |
| 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 Associates2026-05-06 15:28
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-755395.pdf3 pages
Itemised statement totalling $256.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017677 | 2026-04-29 | Evergreen Cardiovascular Associates | $369.00 | Approved |
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
Clean claim, priced at contract rate.