CLM-2026-030093
Mesa Internal Medicine Associates, Internal Medicine. Service 2025-12-11 at office (POS 11). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Linda Davis
- Member ID
- UHC-55392-40
- Date of birth
- 1986-12-25
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414462
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4049
- Coverage period
- 2023-01-01 to present
- Deductible
- $289.24 of $2,500.0012%
- Out-of-pocket maximum
- $1,112.64 of $10,000.0011%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4707375216
- Network
- In network
- Rendering NPI
- 9052711667
- Location
- Los Angeles, CA · TIN 98-0064995
- Authorisation / referral
- none / REF735178
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 | $210.00 | $130.20 | — | — | Review |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1,2 | $68.00 | $42.16 | — | — | Review |
| Totals | $278.00 | $172.36 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-230089
- 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-001946 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-11: CORE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 27 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 Internal Medicine Associates (4707375216). | |
| 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 unspecified atrial fibrillation. Note dictated; signature pending.”. 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 Internal Medicine Associates2025-12-11 09:38
Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-07 01:53
Rendering provider signature missing on the attached note. Development letter sent to provider.
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 unspecified atrial fibrillation. Note dictated; signature pending.”.
- AI recommendationPended2026-10-21 14:15The claim is pended due to incomplete documentation. The clinical note indicates that the patient was seen for unspecified atrial fibrillation, but the note is dictated and the signature is pending. A development letter has been sent to the provider to obtain the missing signature. Once the signature is obtained and the documentation is complete, the claim can be re-evaluated for approval.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · e9059c04
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032504 | 2026-02-06 | Meadow Diagnostic Imaging | $809.00 | Denied |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim is pended due to incomplete documentation. The clinical note indicates that the patient was seen for unspecified atrial fibrillation, but the note is dictated and the signature is pending. A development letter has been sent to the provider to obtain the missing signature. Once the signature is obtained and the documentation is complete, the claim can be re-evaluated for approval.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO16 Claim lacks information needed for adjudication
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.