CLM-2026-025476
Mesa Family Practice, Family Medicine. Service 2026-05-23 at office (POS 11). Received 2026-06-30.
Member
Resolved through the identity graph
- Member
- Shirleey Torres
- Member ID
- UHC-32432-85
- Date of birth
- 1992-01-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-419631
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6186
- Coverage period
- 2021-02-01 to present
- Deductible
- $84.02 of $500.0017%
- Out-of-pocket maximum
- $462.68 of $1,000.0046%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3505890145
- Network
- In network
- Rendering NPI
- 6766421815
- Location
- Atlanta, GA · TIN 15-9233501
- 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 | $218.00 | $135.16 | $20.00 | $115.16 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 1,2 | $230.00 | $142.60 | $0.00 | $142.60 | Paid |
| 3 | 36415 | Venipuncture | — | 1 | 2 | $25.00 | $15.50 | $0.00 | $15.50 | Paid |
| Totals | $473.00 | $293.26 | $20.00 | $273.26 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-940608
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-036790 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-23: MEDICARE-ADV-A (MA), effective 2021-02-01. | |
| Timely filing | Pass | Received 38 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 (3505890145). | |
| 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 Family Practice2026-05-23 18:32
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-30 03:57
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-30 10:03
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-940608.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.