CLM-2026-018240
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-07-18 at office (POS 11). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Joyce Sanchez
- Member ID
- UHC-16910-09
- Date of birth
- 1966-10-24
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-424660
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1779
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,223.08 of $2,500.0049%
- Out-of-pocket maximum
- $1,698.77 of $7,500.0023%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1153640218
- Network
- In network
- Rendering NPI
- 5578622354
- Location
- Houston, TX · TIN 60-7207391
- Authorisation / referral
- none / REF207402
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 | — | 1 | 1 | $315.00 | $195.30 | $30.00 | $165.30 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $85.00 | $52.70 | $0.00 | $52.70 | Paid |
| Totals | $400.00 | $248.00 | $30.00 | $218.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-755352
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013125 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-18: CORE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 40 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 (1153640218). | |
| 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 Associates2026-07-18 12:42
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011006 | 2026-04-11 | Pinecrest Bone and Joint Center | $10,067.00 | Denied |
| CLM-2026-011005 | 2026-04-11 | Pinecrest Bone and Joint Center | $10,067.00 | 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.