CLM-2026-025096
Mesa Medical Group, Family Medicine. Service 2026-02-06 at office (POS 11). Received 2026-03-06.
Member
Resolved through the identity graph
- Member
- Priya Price
- Member ID
- UHC-86266-54
- Date of birth
- 1991-09-09
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-422700
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4104
- Coverage period
- 2021-12-01 to present
- Deductible
- $395.99 of $500.0079%
- Out-of-pocket maximum
- $434.88 of $1,500.0029%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7662849547
- Network
- In network
- Rendering NPI
- 2123835243
- Location
- Los Angeles, CA · TIN 30-7296562
- 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 | $276.00 | $171.12 | — | — | DeniedCO18 |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $35.00 | $21.70 | — | — | DeniedCO18 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $211.00 | $130.82 | — | — | DeniedCO18 |
| Totals | $522.00 | $323.64 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-417948
- 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-013052 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-06: SELECT-EPO (EPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-025095: 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 (7662849547). | |
| 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 Group2026-02-06 10:11
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-03-06 06:28
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
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-2026-025095: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029312 | 2026-06-22 | Canyon Medical Group | $315.00 | Approved |
| CLM-2026-027540 | 2026-02-22 | Heritage Imaging Center | $191.00 | Approved |
| CLM-2026-025095 | 2026-02-06 | Mesa Medical Group | $522.00 | 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.