CLM-2026-030050
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-09-08 to 2026-09-09 at inpatient hospital (POS 21). Received 2026-10-01.
Member
Resolved through the identity graph
- Member
- Ruth Jordan
- Member ID
- UHC-16459-44
- Date of birth
- 2005-02-16
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-432540
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1718
- Coverage period
- 2021-01-01 to present
- Deductible
- $1,664.48 of $3,500.0048%
- Out-of-pocket maximum
- $4,564.44 of $14,000.0033%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 7667531934
- Network
- Out of network
- Rendering NPI
- 1937408593
- Location
- Miami, FL · TIN 27-5098805
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $237.00 | $106.65 | — | — | DeniedCO204 |
| Totals | $237.00 | $106.65 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-169621
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-09-08 to 2026-09-09
- 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-018347 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-08: SELECT-EPO (EPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 22 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 | Fail | CO204 | Billing provider 7667531934 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Internal Medicine Associates2026-09-09 09:10
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-01 02:48
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-01 14:12
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-169621.pdf8 pages
Itemised statement totalling $237.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 7667531934 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010969 | 2026-02-04 | Summit Counseling Center | $153.00 | Approved |
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
No out-of-network benefit on this plan.