CLM-2026-022110
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-07-19 to 2026-07-23 at inpatient hospital (POS 21). Received 2026-07-24.
Member
Resolved through the identity graph
- Member
- Denise Petesr
- Member ID
- UHC-28393-22
- Date of birth
- 1908-10-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-401523
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group N/A
- Coverage period
- 2023-03-01 to present
- Deductible
- $496.78 of $1,000.0050%
- Out-of-pocket maximum
- $7.49 of $2,000.000%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4707375216
- Network
- In network
- Rendering NPI
- 5432683493
- Location
- Los Angeles, CA · TIN 98-0064995
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $235.00 | $129.25 | $129.25 | $0.00 | Paid |
| Totals | $235.00 | $129.25 | $129.25 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-715766
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-19 to 2026-07-20
- 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-025374 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-19: MEDICARE-ADV-A (MA), effective 2023-03-01. | |
| Timely filing | Pass | Received 1 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 Internal Medicine Associates (4707375216). | |
| 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 Internal Medicine Associates2026-07-23 15:09
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-715766.pdf6 pages
Itemised statement totalling $235.00 across 1 line.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016458 | 2026-07-03 | Northgate Clinical Laboratories | $68.00 | Approved |
| CLM-2026-003551 | 2026-03-03 | Mesa Cardiovascular Associates | $737.00 | Approved |
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
Clean claim, priced at contract rate.