CLM-2026-021382
Mesa Medical Group, Family Medicine. Service 2026-02-18 at office (POS 11). Received 2026-02-21.
Member
Resolved through the identity graph
- Member
- Lucia Ryees
- Member ID
- none on golden record
- Date of birth
- 1967-05-26
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-430172
- Relationship
- Child, Fresno, CA
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3131727711
- Network
- In network
- Rendering NPI
- 4099823518
- Location
- Dallas, TX · TIN 70-1042424
- 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 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $286.00 | $177.32 | — | — | PendedIDQ |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 2 | $156.00 | $96.72 | — | — | PendedIDQ |
| Totals | $442.00 | $274.04 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-287627
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000273; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 3 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 Medical Group (3131727711). | |
| 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 Medical Group2026-02-18 11:53
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-02-21 04:19
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-287627.pdf8 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-000273; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Bundling (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.