CLM-2026-020369
Mesa Family Practice, Family Medicine. Service 2025-12-25 at office (POS 11). Received 2026-02-08.
Member
Resolved through the identity graph
- Member
- Hiroshi Harris
- Member ID
- UHC-10926-62
- Date of birth
- 1992-03-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419184
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2690
- Coverage period
- 2021-11-01 to present
- Deductible
- $500.27 of $1,000.0050%
- Out-of-pocket maximum
- $57.48 of $4,000.001%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 5038210378
- 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 | 90471 | Immunization administration | — | 1 | 1 | $34.00 | $21.08 | — | — | Review |
| Totals | $34.00 | $21.08 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-492950
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-002509 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-25: CORE-HMO (HMO), effective 2021-11-01. | |
| Timely filing | Pass | Received 45 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 | Review | CO16 | Documentation incomplete: “Patient seen for encounter for general adult medical examination without abnormal findings”. 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 Practice2025-12-25 13:49
Patient seen for encounter for general adult medical examination without abnormal findings. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-08 04:54
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-08 12:24
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 engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for encounter for general adult medical examination without abnormal findings”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034307 | 2026-01-23 | Riverside Primary Care Associates | $162.00 | Approved |
| CLM-2026-008298 | 2025-12-03 | Unity Cardiovascular Associates | $679.00 | 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.