CLM-2026-029528
Mesa Diabetes Center, Endocrinology. Service 2026-05-08 at office (POS 11). Received 2026-05-26.
Member
Resolved through the identity graph
- Member
- Christine Rice
- Member ID
- UHC-59929-46
- Date of birth
- 1958-01-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-408647
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4199
- Coverage period
- 2024-12-01 to 2026-05-03
- Deductible
- $1,246.41 of $3,500.0036%
- Out-of-pocket maximum
- $1,429.16 of $10,500.0014%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 3634244123
- Network
- In network
- Rendering NPI
- 2135486860
- Location
- Scottsdale, AZ · TIN 19-2073831
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $327.00 | $202.74 | — | — | DeniedCO27 |
| Totals | $327.00 | $202.74 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-419824
- 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-032318 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-08 is after coverage terminated on 2026-05-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 18 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 Diabetes Center (3634244123). | |
| 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 Diabetes Center2026-05-08 18:37
Established patient presents with thyrotoxicosis, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-26 00:53
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-08 is after coverage terminated on 2026-05-03.
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.