Claims workbench/CLM-2026-028978
Professional claim · CMS-1500 · EDI 837P

CLM-2026-028978

Mesa Internal Medicine Associates, Internal Medicine. Service 2026-06-03 at office (POS 11). Received 2026-07-15.

Approved
Billed
$75.00
1 line
Allowed
$46.50
contract rate applied
Plan pays
$21.50
approved
Member owes
$25.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Melissa Jordan
Member ID
UHC-06365-30
Date of birth
1981-10-21
Identity
Verified5 records, confidence 1.00
Claim record
CLMCLM-411726
Relationship
Spouse, Mesa, AZ

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-4732
Coverage period
2024-05-01 to present
Deductible
$446.29 of $500.0089%
Out-of-pocket maximum
$442.00 of $2,000.0022%
Copays
office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits
2 of 20 used

Provider

Billing and rendering

Billing provider
Mesa Internal Medicine Associates
Internal Medicine · taxonomy 207R00000X
NPI
4707375216
Network
In network
Rendering NPI
8962182944
Location
Los Angeles, CA · TIN 98-0064995
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180053Comprehensive metabolic panel—11$75.00$46.50$25.00$21.50Paid
Totals$75.00$46.50$25.00$21.50
Diagnoses (ICD-10-CM)
  • 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
  • 2. I10 Essential (primary) hypertension
Claim header
Patient account
PA-373629
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

CheckResultCodeDetail
Member identityPassAttached to MBR-032427 (verified, link confidence 1.00).
EligibilityPassActive on 2026-06-03: OPTIONS-PPO (PPO), effective 2024-05-01.
Timely filingPassReceived 42 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Mesa Internal Medicine Associates (4707375216).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Mesa Internal Medicine Associates2026-06-03 14:45

    Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$75.00
Plan discount
$28.50
contracted rate
Plan paid
$21.50
You may owe
$25.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0131062026-04-29Canyon Regional Medical Center$1,129.00Approved

AI recommendation

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

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity