CLM-2026-020112
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-09-05 to 2026-09-07 at inpatient hospital (POS 21). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- James Thompson
- Member ID
- UHC-57559-48
- Date of birth
- 1979-07-14
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-400786
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2654
- Coverage period
- 2023-09-01 to 2026-02-06
- Deductible
- $372.04 of $500.0074%
- Out-of-pocket maximum
- $448.06 of $1,500.0030%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1153640218
- Network
- In network
- Rendering NPI
- 7733462643
- Location
- Houston, TX · TIN 60-7207391
- 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 | $253.00 | $139.15 | — | — | DeniedCO27 |
| Totals | $253.00 | $139.15 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-104032
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-09-05 to 2026-09-07
- 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-025563 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-05 is after coverage terminated on 2026-02-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 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 Associates2026-09-07 12:54
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-03 05:24
Attachments
Documents received with the claim
- Itemized billitemized_PA-104032.pdf9 pages
Itemised statement totalling $253.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-05 is after coverage terminated on 2026-02-06.
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.