CLM-2026-020656
Mesa Family Practice, Family Medicine. Service 2026-01-19 at office (POS 11). Received 2026-02-25.
Member
Resolved through the identity graph
- Member
- Debra Aguilar
- Member ID
- UHC-12963-51
- Date of birth
- 1995-07-07
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-432376
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3121
- Coverage period
- 2024-04-01 to present
- Deductible
- $316.33 of $1,000.0032%
- Out-of-pocket maximum
- $371.45 of $4,000.009%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 1920658659
- 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 | $25.00 | $15.50 | — | — | DeniedCO18 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $287.00 | $177.94 | — | — | DeniedCO18 |
| Totals | $312.00 | $193.44 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-926134
- 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-012389 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-19: CORE-HMO (HMO), effective 2024-04-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-020655: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Family Practice2026-01-19 09:27
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-02-25 02:03
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-020655: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025780 | 2026-06-26 | Desert Reference Lab | $118.00 | Approved |
| CLM-2026-004854 | 2026-06-19 | Riverside Clinical Laboratories | $110.00 | Needs review |
| CLM-2026-022525 | 2026-01-25 | Heritage Behavioral Health | $3,577.00 | Needs review |
| CLM-2026-020655 | 2026-01-19 | Mesa Family Practice | $312.00 | Approved |
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
Exact duplicate of an earlier submission.