CLM-2026-021230
Mesa Diabetes Center, Endocrinology. Service 2026-04-11 at office (POS 11). Received 2026-05-12.
Member
Resolved through the identity graph
- Member
- Rachel Maldonado
- Member ID
- UHC-21658-41
- Date of birth
- 1992-09-16
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-418172
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-0636
- Coverage period
- 2022-07-01 to 2026-06-01
- Deductible
- $19.90 of $2,500.001%
- Out-of-pocket maximum
- $789.36 of $10,000.008%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 2446853584
- Network
- In network
- Rendering NPI
- 4910862935
- Location
- Denver, CO · TIN 89-4122070
- 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 | 83036 | Hemoglobin A1c | 59 | 1 | 1 | $37.00 | $22.94 | — | — | Review |
| 2 | 95251 | Continuous glucose monitoring, analysis | 59 | 1 | 1 | $174.00 | $107.88 | — | — | Review |
| Totals | $211.00 | $130.82 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-725681
- 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-026044 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-04-11: NULL (PPO), effective 2022-07-01, terms 2026-06-01. | |
| Timely filing | Pass | Received 31 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 Diabetes Center (2446853584). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Diabetes Center2026-04-11 17:29
Patient seen for thyrotoxicosis, unspecified. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-05-12 00:31
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-12 11:46
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-725681.pdf15 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
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
Modifier 59 supported: distinct anatomical site documented.