Claims workbench/CLM-2026-024542

Professional claim · CMS-1500 · Paper

CLM-2026-024542

Mesa Medical Group, Family Medicine. Service 2026-08-06 at office (POS 11). Received 2026-08-31.

Denied

Billed

$225.00

1 line

Allowed

$139.50

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Olivia Hunt
Member ID: none on golden record
Date of birth: 1987-09-16
Identity: Verified3 records, confidence 0.94
Claim record: CLMCLM-402511
Relationship: Spouse, Atlanta, GA

Coverage and accumulators

Found by name and date of birth

Plan: CORE-HMO HMO group GRP-9019
Coverage period: 2024-07-01 to present
Deductible: $114.43 of $1,500.008%
Out-of-pocket maximum: $1,194.42 of $3,000.0040%
Copays: office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Mesa Medical Group
Family Medicine · taxonomy 207Q00000X
NPI: 3131727711
Network: In network
Rendering NPI: 4391010426
Location: Dallas, TX · TIN 70-1042424
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	99395	Preventive visit, 18-39 years	—	1	1	$225.00	$139.50	—	—	DeniedCO18
Totals						$225.00	$139.50	—	—

Diagnoses (ICD-10-CM)

1. I10 Essential (primary) hypertensionprincipal
2. M54.50 Low back pain, unspecified
3. E11.9 Type 2 diabetes mellitus without complications

Claim header

Patient account: PA-247578
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-028996 (verified, link confidence 0.94).
Eligibility	Note		Active on 2026-08-06: CORE-HMO (HMO), effective 2024-07-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 25 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-024541: 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 (3131727711).
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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Mesa Medical Group2026-08-06 11:38
Patient seen for essential (primary) hypertension.
SystemSystem: Claims system2026-08-31 00:30
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-31 14:38
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Active on 2026-08-06: CORE-HMO (HMO), effective 2024-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. Duplicate check: Exact duplicate of CLM-2026-024541: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-001233	2026-05-08	Mesa Cardiovascular Associates	$1,912.00	Denied
CLM-2026-024541	2026-08-06	Mesa Medical Group	$225.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity