CLM-2026-029298
Mesa Primary Care Associates, Family Medicine. Service 2026-09-07 at office (POS 11). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Frank Thompson
- Member ID
- UHC-47481-78
- Date of birth
- 1982-09-06
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-421503
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3889
- Coverage period
- 2022-03-01 to 2026-05-14
- Deductible
- $473.33 of $1,000.0047%
- Out-of-pocket maximum
- $1,369.99 of $4,000.0034%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 1256425335
- Network
- In network
- Rendering NPI
- 8951722445
- Location
- Nashville, TN · TIN 57-2751445
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $217.00 | $134.54 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | 25 | 1 | 2 | $15.00 | $9.30 | — | — | DeniedCO27 |
| 3 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1,2 | $208.00 | $128.96 | — | — | DeniedCO27 |
| Totals | $440.00 | $272.80 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-778618
- 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-007091 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-07 is after coverage terminated on 2026-05-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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 Primary Care Associates (1256425335). | |
| 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 Primary Care Associates2026-09-07 11:34
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-10 01:16
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-10 08:11
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-07 is after coverage terminated on 2026-05-14.
Other claims for this member
Same resolved identity
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
Service after coverage termination.