CLM-2026-021755
Mesa Diabetes Center, Endocrinology. Service 2026-07-20 at office (POS 11). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Bradley Torres
- Member ID
- UHC-41314-35
- Date of birth
- 1969-02-06
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-422576
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8676
- Coverage period
- 2023-01-01 to present
- Deductible
- $386.82 of $500.0077%
- Out-of-pocket maximum
- $860.95 of $2,000.0043%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 2446853584
- Network
- In network
- Rendering NPI
- 9549451828
- Location
- Denver, CO · TIN 89-4122070
- Authorisation / referral
- none / REF151072
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 | $301.00 | $186.62 | $40.00 | $146.62 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $78.00 | $48.36 | $0.00 | $48.36 | Paid |
| Totals | $379.00 | $234.98 | $40.00 | $194.98 | ||||||
- 1. E03.9 Hypothyroidism, unspecifiedprincipal
- 2. E05.90 Thyrotoxicosis, unspecified
- Patient account
- PA-296638
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033506 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-20: CORE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 29 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) | 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 Center2026-07-20 18:12
Established patient presents with hypothyroidism, unspecified; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-08-18 00:10
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-296638.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.