CLM-2026-022570
Mesa Family Practice, Family Medicine. Service 2026-10-04 at office (POS 11). Received 2026-10-21.
Member
Resolved through the identity graph
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0904
- Coverage period
- 2022-02-01 to present
- Deductible
- $441.53 of $1,000.0044%
- Out-of-pocket maximum
- $1,635.14 of $4,000.0041%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9198076652
- Network
- In network
- Rendering NPI
- 7584280821
- Location
- Denver, CO · TIN 38-9829181
- 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 | $296.00 | $183.52 | — | — | PendedCO16 |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $19.00 | $11.78 | — | — | PendedCO16 |
| 3 | 90471 | Immunization administration | — | 1 | 1,2 | $33.00 | $20.46 | — | — | PendedCO16 |
| Totals | $348.00 | $215.76 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-444094
- 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 | Fail | CO16 | Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication |
| Eligibility | Pass | Active on 2026-10-04: SELECT-EPO (EPO), effective 2022-02-01. | |
| 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 Family Practice (9198076652). | |
| 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 Practice2026-10-04 12:18
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-10-21 00:56
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-21 08:54
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 enginePended2026-10-21 13:43Member identity: Claim record is not attached to a resolved identity.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.