CLM-2026-021787
Mesa Family Practice, Family Medicine. Service 2025-12-18 at office (POS 11). Received 2026-07-03.
Member
Resolved through the identity graph
- Member
- Lucia Vargas
- Member ID
- UHC-57841-42
- Date of birth
- 1975-11-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-401980
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0983
- Coverage period
- 2025-01-01 to present
- Deductible
- $418.92 of $1,000.0042%
- Out-of-pocket maximum
- $1,072.97 of $3,000.0036%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7916099477
- Network
- In network
- Rendering NPI
- 2631818178
- Location
- Miami, FL · TIN 48-0020072
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $240.00 | $148.80 | — | — | DeniedCO29 |
| Totals | $240.00 | $148.80 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-219068
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000952 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-18: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Fail | CO29 | Received 197 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Family Practice (7916099477). | |
| 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 Family Practice2025-12-18 10:08
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-03 03:43
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-03 13:26
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 197 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024259 | 2026-02-15 | Mesa Physical Therapy | $366.00 | Denied |
| CLM-2026-024258 | 2026-02-15 | Mesa Physical Therapy | $366.00 | Approved |
| CLM-2026-024069 | 2025-12-29 | Canyon Reference Lab | $79.00 | 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
Received after the timely-filing limit.