CLM-2026-017712
Mesa Diabetes Center, Endocrinology. Service 2025-11-02 at office (POS 11). Received 2026-05-04.
Member
Resolved through the identity graph
- Member
- Camila Rogers
- Member ID
- UHC-70835-52
- Date of birth
- 2004-02-15
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-400978
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group N/A
- Coverage period
- 2025-09-01 to present
- Deductible
- $1,834.28 of $2,500.0073%
- Out-of-pocket maximum
- $3,574.66 of $7,500.0048%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 3634244123
- Network
- In network
- Rendering NPI
- 6172976485
- Location
- Scottsdale, AZ · TIN 19-2073831
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $36.00 | $22.32 | — | — | DeniedCO29 |
| 2 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1,2 | $169.00 | $104.78 | — | — | DeniedCO29 |
| Totals | $205.00 | $127.10 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E05.90 Thyrotoxicosis, unspecified
- Patient account
- PA-472437
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029032 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-11-02: MEDICARE-ADV-A (MA), effective 2025-09-01. | |
| Timely filing | Fail | CO29 | Received 183 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (3634244123). | |
| 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 Diabetes Center2025-11-02 13:46
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-04 02:13
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-04 17:09
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 12:44Timely filing: Received 183 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015319 | 2026-03-24 | Northgate Counseling Center | $333.00 | Approved |
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
Received after the timely-filing limit.