CLM-2026-018670
Mesa Family Practice, Family Medicine. Service 2026-06-16 at office (POS 11). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Diana Owens
- Member ID
- none on golden record
- Date of birth
- 1973-10-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-416292
- Relationship
- Child
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group NULL
- Coverage period
- 2025-11-01 to 2026-05-07
- Deductible
- $1,527.80 of $2,500.0061%
- Out-of-pocket maximum
- $3,323.28 of $10,000.0033%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 6870090985
- Location
- San Diego, CA · TIN 89-4780194
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $207.00 | $128.34 | — | — | DeniedCO27 |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1 | $222.00 | $137.64 | — | — | DeniedCO27 |
| Totals | $429.00 | $265.98 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-381296
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001899; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-06-16 is after coverage terminated on 2026-05-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 29 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 (7652159394). | |
| 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 Family Practice2026-06-16 12:58
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-15 01:15
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-001899; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-06-16 is after coverage terminated on 2026-05-07.
Other claims for this member
Same resolved identity
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
Service after coverage termination.