CLM-2026-022243
Mesa Primary Care Associates, Family Medicine. Service 2026-08-26 at office (POS 11). Received 2026-09-12.
Member
Resolved through the identity graph
- Member
- Jake Gordon
- Member ID
- UHC-21175-07
- Date of birth
- 1953-04-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-407931
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8664
- Coverage period
- 2024-03-01 to 2026-08-07
- Deductible
- $2,080.84 of $2,500.0083%
- Out-of-pocket maximum
- $4,445.02 of $10,000.0044%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1256425335
- Network
- In network
- Rendering NPI
- 8435320188
- Location
- Nashville, TN · TIN 57-2751445
- 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 | $243.00 | $150.66 | — | — | DeniedCO27 |
| Totals | $243.00 | $150.66 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-979290
- 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-006486 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-26 is after coverage terminated on 2026-08-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 17 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 Primary Care Associates (1256425335). | |
| 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 Primary Care Associates2026-08-26 14:57
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-09-12 00:36
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-12 13:43
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-26 is after coverage terminated on 2026-08-07.
Other claims for this member
Same resolved identity
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
Service after coverage termination.