Professional claim · CMS-1500 · EDI 837P
CLM-2026-022833
Mesa Medical Group, Internal Medicine. Service 2026-09-27 at office (POS 11). Received 2026-10-05.
Approved
Billed
$272.00
1 line
Allowed
$168.64
contract rate applied
Plan pays
$148.64
approved
Member owes
$20.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Charlotte Ortiz
- Member ID
- UHC-52389-49
- Date of birth
- 2002-10-16
- Identity
- Verified6 records, confidence 0.98
- Claim record
- CLMCLM-400265
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7783
- Coverage period
- 2024-12-01 to present
- Deductible
- $93.78 of $2,500.004%
- Out-of-pocket maximum
- $1,262.31 of $10,000.0013%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9057332212
- Network
- In network
- Rendering NPI
- 1573899485
- Location
- San Diego, CA · TIN 98-1862745
- 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 | $272.00 | $168.64 | $20.00 | $148.64 | Paid |
| Totals | $272.00 | $168.64 | $20.00 | $148.64 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
Claim header
- Patient account
- PA-636017
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001356 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-09-27: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 8 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 Medical Group (9057332212). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Medical Group2026-09-27 17:44
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$272.00
Plan discount
$103.36
contracted rate
Plan paid
$148.64
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022834 | 2026-09-27 | Mesa Medical Group | $272.00 | Denied |
| CLM-2026-016449 | 2026-07-18 | Canyon Primary Care Associates | $335.00 | Approved |
| CLM-2026-031922 | 2026-03-15 | Desert Primary Care Associates | $61.00 | Approved |
| CLM-2026-020849 | 2026-01-01 | Riverside Imaging Center | $2,250.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.