CLM-2026-024431
Mesa Family Practice, Family Medicine. Service 2025-12-02 at office (POS 11). Received 2026-01-13.
Member
Resolved through the identity graph
- Member
- Carol Banks
- Member ID
- UHC-53162-58
- Date of birth
- 1999-02-17
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-410738
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5632
- Coverage period
- 2024-10-01 to present
- Deductible
- $223.50 of $1,000.0022%
- Out-of-pocket maximum
- $35.81 of $3,000.001%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7916099477
- Network
- In network
- Rendering NPI
- 1446665410
- Location
- Miami, FL · TIN 48-0020072
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $206.00 | $127.72 | — | — | Review |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $16.00 | $9.92 | — | — | Review |
| 3 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $196.00 | $121.52 | — | — | Review |
| Totals | $418.00 | $259.16 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-674637
- 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-003949 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-02: MEDICARE-ADV-A (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 42 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 (7916099477). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with low back pain, unspecified; symptoms reviewed and vitals”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Family Practice2025-12-02 10:16
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-13 06:57
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Established patient presents with low back pain, unspecified; symptoms reviewed and vitals”.
- AI recommendationPended2026-10-23 17:08The claim is pended due to incomplete documentation (CO16). The clinical note is dictated but not signed, and a development letter has been sent to the provider for the signature [N1, N2]. The claim will be held until the provider submits the signed clinical note.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 17:08 · ba64b5dc
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031008 | 2026-08-17 | Meadow Heart Institute | $1,047.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim is pended due to incomplete documentation (CO16). The clinical note is dictated but not signed, and a development letter has been sent to the provider for the signature [N1, N2]. The claim will be held until the provider submits the signed clinical note.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO16 Claim lacks information needed for adjudication
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.