CLM-2026-020052
Mesa Internal Medicine Associates, Internal Medicine. Service 2025-12-16 to 2025-12-20 at inpatient hospital (POS 21). Received 2026-01-16.
Member
Resolved through the identity graph
- Member
- Samuel Price
- Member ID
- UHC-07622-81
- Date of birth
- 1987-11-25
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-400766
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7510
- Coverage period
- 2021-10-01 to present
- Deductible
- $440.07 of $3,500.0013%
- Out-of-pocket maximum
- $163.86 of $10,500.002%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 7667531934
- Network
- Out of network
- Rendering NPI
- 4472014206
- Location
- Miami, FL · TIN 27-5098805
- Authorisation / referral
- none / REF504349
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 | $202.00 | $90.90 | — | — | DeniedCO204 |
| Totals | $202.00 | $90.90 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-831904
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-12-16 to 2025-12-18
- 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-004836 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-16: CORE-HMO (HMO), effective 2021-10-01. | |
| Timely filing | Pass | Received 27 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 | Fail | CO204 | Billing provider 7667531934 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2025-12-20 18:44
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-16 06:13
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-831904.pdf7 pages
Itemised statement totalling $202.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 7667531934 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.