CLM-2026-017366
Mesa Family Practice, Family Medicine. Service 2026-08-28 at office (POS 11). Received 2026-10-09.
Member
Resolved through the identity graph
- Member
- John Sims
- Member ID
- UHC-98485-42
- Date of birth
- 1979-06-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-414694
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1667
- Coverage period
- 2025-11-01 to present
- Deductible
- $457.43 of $1,000.0046%
- Out-of-pocket maximum
- $152.30 of $2,000.008%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7916099477
- Network
- In network
- Rendering NPI
- 1360882793
- Location
- Miami, FL · TIN 48-0020072
- 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 | 36415 | Venipuncture | 59 | 1 | 1 | $25.00 | $15.50 | — | — | Review |
| 2 | 90471 | Immunization administration | 59 | 1 | 1 | $30.00 | $18.60 | — | — | Review |
| Totals | $55.00 | $34.10 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-950441
- 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-003473 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-28: MEDICARE-ADV-B (MA), effective 2025-11-01. | |
| Timely filing | Pass | Received 42 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 Family Practice (7916099477). | |
| 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 Family Practice2026-08-28 12:03
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-10-09 00:49
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-950441.pdf7 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012517 | 2026-01-28 | Evergreen Counseling Center | $449.00 | Approved |
| CLM-2026-011330 | 2025-12-10 | Summit Regional Medical Center | $1,170.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Bundled code pair; modifier 59 not supported by the operative note.