CLM-2026-025674
Mesa Family Practice, Family Medicine. Service 2026-06-23 at office (POS 11). Received 2026-08-05.
Member
Resolved through the identity graph
- Member
- Mara Reynolds
- Member ID
- UHC-36945-54
- Date of birth
- 1984-04-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-422915
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2964
- Coverage period
- 2025-05-01 to present
- Deductible
- $2,826.98 of $3,500.0081%
- Out-of-pocket maximum
- $5,458.27 of $14,000.0039%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 7652159394
- Network
- In network
- Rendering NPI
- 8909495854
- Location
- San Diego, CA · TIN 89-4780194
- 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 | $217.00 | $134.54 | — | — | Review |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $16.00 | $9.92 | — | — | Review |
| Totals | $233.00 | $144.46 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-283004
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040733 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-23: OPTIONS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 43 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 (7652159394). | |
| 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: “Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature ”. 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 Practice2026-06-23 12:48
Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature pending.
- SystemSystem: Claims system2026-08-05 06:59
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-05 13:29
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for type 2 diabetes mellitus without complications. Note dictated; signature ”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.