CLM-2026-021748
Mesa Diabetes Center, Endocrinology. Service 2026-01-27 at office (POS 11). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Chapman Kayal
- Member ID
- UHC-86296-21
- Date of birth
- 1951-09-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-406653
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6681
- Coverage period
- 2024-06-01 to present
- Deductible
- $1,010.18 of $2,500.0040%
- Out-of-pocket maximum
- $207.56 of $5,000.004%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 3634244123
- Network
- In network
- Rendering NPI
- 5764951872
- Location
- Scottsdale, AZ · TIN 19-2073831
- Authorisation / referral
- none / REF977931
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 | — | 1 | 1 | $325.00 | $201.50 | — | — | DeniedCO18 |
| Totals | $325.00 | $201.50 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E03.9 Hypothyroidism, unspecified
- Patient account
- PA-840053
- 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-015802 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-27: NAVIGATE-HMO (HMO), effective 2024-06-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-021747: 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 Diabetes Center (3634244123). | |
| 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 Diabetes Center2026-01-27 12:38
Follow-up for thyrotoxicosis, unspecified. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-03-08 01:21
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
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-2026-021747: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021747 | 2026-01-27 | Mesa Diabetes Center | $325.00 | 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
Different billing provider; separately payable.