CLM-2026-021979
Mesa Family Practice, Family Medicine. Service 2026-01-09 at office (POS 11). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Sandra Patel
- Member ID
- UHC-95354-02
- Date of birth
- 1950-08-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-431116
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2650
- Coverage period
- 2022-07-01 to present
- Deductible
- $810.55 of $3,500.0023%
- Out-of-pocket maximum
- $8.00 of $10,500.000%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 1025809512
- Location
- San Diego, CA · TIN 89-4780194
- 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 | — | 1 | 1 | $298.00 | $184.76 | — | — | DeniedCO18 |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $18.00 | $11.16 | — | — | DeniedCO18 |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $180.00 | $111.60 | — | — | DeniedCO18 |
| Totals | $496.00 | $307.52 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-940743
- 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-004350 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-09: OPTIONS-PPO (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-021978: 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 Family Practice (7652159394). | |
| 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 Practice2026-01-09 09:57
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-18 00:10
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-18 11:08
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 13:43Duplicate check: Exact duplicate of CLM-2026-021978: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022060 | 2026-07-14 | Desert Rehabilitation Center | $318.00 | Needs review |
| CLM-2026-021978 | 2026-01-09 | Mesa Family Practice | $496.00 | 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
Exact duplicate of an earlier submission.