CLM-2026-023342
Mesa Medical Group, Internal Medicine. Service 2025-12-31 at office (POS 11). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Emily Ward
- Member ID
- UHC-88538-10
- Date of birth
- 1981-03-05
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-426074
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-3806
- Coverage period
- 2024-11-01 to present
- Deductible
- $609.26 of $1,000.0061%
- Out-of-pocket maximum
- $299.19 of $2,000.0015%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9057332212
- Network
- In network
- Rendering NPI
- 8486977472
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $88.00 | $54.56 | — | — | DeniedCO18 |
| Totals | $88.00 | $54.56 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-890423
- 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-009039 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-31: N/A (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-023341: 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 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Medical Group2025-12-31 18:55
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-03 02:10
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-03 12:36
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-023341: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015654 | 2026-08-24 | Harbor Cardiovascular Associates | $1,681.00 | Approved |
| CLM-2026-001595 | 2026-04-11 | Riverside Medical Group | $40.00 | Approved |
| CLM-2026-023341 | 2025-12-31 | Mesa Medical Group | $88.00 | 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.