CLM-2026-018781
Mesa Family Practice, Family Medicine. Service 2026-07-07 at office (POS 11). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Janice Henry
- Member ID
- UHC-34207-15
- Date of birth
- 1944-10-20
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-409105
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9509
- Coverage period
- 2024-12-01 to present
- Deductible
- $233.26 of $1,000.0023%
- Out-of-pocket maximum
- $241.26 of $4,000.006%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7916099477
- Network
- In network
- Rendering NPI
- 8082026922
- Location
- Miami, FL · TIN 48-0020072
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $214.00 | $132.68 | — | — | Review |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $335.00 | $207.70 | — | — | Review |
| Totals | $549.00 | $340.38 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-833128
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-010709 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-07: CORE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 24 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 (7916099477). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for encounter for general adult medical examination without abnormal findings. P”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Family Practice2026-07-07 16:13
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-31 02:11
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-31 08:15
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for encounter for general adult medical examination without abnormal findings. P”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021369 | 2026-06-24 | Canyon Reference Lab | $95.00 | Denied |
| CLM-2026-014499 | 2026-03-25 | Northgate Medical Group | $30.00 | 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
Development letter outstanding.