Professional claim · CMS-1500 · EDI 837P
CLM-2026-021713
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-05-08 at office (POS 11). Received 2026-06-08.
DeniedOut of network
Billed
$345.00
1 line
Allowed
$155.25
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27, CO204
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Anna Clark
- Member ID
- UHC-98211-28
- Date of birth
- 1952-04-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-413994
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5975
- Coverage period
- 2024-04-01 to 2026-01-05
- Deductible
- $745.82 of $1,500.0050%
- Out-of-pocket maximum
- $1,318.10 of $6,000.0022%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 7667531934
- Network
- Out of network
- Rendering NPI
- 6780137967
- Location
- Miami, FL · TIN 27-5098805
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $345.00 | $155.25 | — | — | DeniedCO27 |
| Totals | $345.00 | $155.25 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-300017
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029649 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-08 is after coverage terminated on 2026-01-05. Expenses incurred after coverage terminated |
| 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 | Fail | CO204 | Billing provider 7667531934 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Internal Medicine Associates2026-05-08 11:49
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-06-08 04:25
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-08 is after coverage terminated on 2026-01-05. Provider network: Billing provider 7667531934 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013366 | 2026-04-01 | Evergreen Internal Medicine Associates | $399.00 | Denied |
| CLM-2026-023272 | 2026-04-08 | Valley Digestive Health Center | $272.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.