CLM-2026-017777
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-01-20 to 2026-01-24 at inpatient hospital (POS 21). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Willie Lawrence
- Member ID
- UHC-44326-19
- Date of birth
- 1981-01-26
- Identity
- Verified3 records, confidence 0.91
- Claim record
- CLMCLM-403811
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3910
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,342.01 of $1,500.0089%
- Out-of-pocket maximum
- $1,129.96 of $3,000.0038%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4707375216
- Network
- In network
- Rendering NPI
- 2682267226
- Location
- Los Angeles, CA · TIN 98-0064995
- Authorisation / referral
- none / REF242679
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 | $186.00 | $102.30 | — | — | Review |
| Totals | $186.00 | $102.30 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-430626
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-20 to 2026-01-24
- 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-015149 (verified, link confidence 0.91). | |
| Eligibility | Pass | Active on 2026-01-20: CORE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-017776, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Internal Medicine Associates (4707375216). | |
| 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 Associates2026-01-24 10:03
Patient seen for type 2 diabetes mellitus with hyperglycemia. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-03-04 00:24
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
- Itemized billitemized_PA-430626.pdf2 pages
Itemised statement totalling $186.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-017776, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015416 | 2026-05-09 | Unity Counseling Center | $422.00 | Approved |
| CLM-2026-017776 | 2026-01-20 | Unity Medical Group | $186.00 | 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
Different billing provider; separately payable.