CLM-2026-018734
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-02-09 to 2026-02-13 at inpatient hospital (POS 21). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Nicole Gonzales
- Member ID
- UHC-80545-64
- Date of birth
- 1941-02-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431362
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1979
- Coverage period
- 2024-10-01 to present
- Deductible
- $364.70 of $500.0073%
- Out-of-pocket maximum
- $216.28 of $1,000.0022%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 7667531934
- Network
- Out of network
- Rendering NPI
- 6329383452
- Location
- Miami, FL · TIN 27-5098805
- Authorisation / referral
- none / none
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 | $242.00 | $108.90 | $108.90 | $0.00 | Paid |
| Totals | $242.00 | $108.90 | $108.90 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-984275
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-02-09 to 2026-02-10
- 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-005921 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-09: MEDICARE-ADV-B (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 38 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Associates2026-02-13 09:20
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-984275.pdf4 pages
Itemised statement totalling $242.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028157 | 2026-03-25 | Heritage Orthopedic Specialists | $10,502.00 | Denied |
| CLM-2026-000072 | 2026-01-01 | Summit Clinical Laboratories | $115.00 | Needs review |
| CLM-2026-000071 | 2026-01-01 | Canyon Clinical Laboratories | $115.00 | 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.