CLM-2026-030609
Mesa Internal Medicine Associates, Internal Medicine. Service 2025-11-29 at office (POS 11). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Joyce Medina
- Member ID
- UHC-72617-64
- Date of birth
- 1948-12-10
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417165
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6814
- Coverage period
- 2021-07-01 to 2026-03-24
- Deductible
- $191.99 of $1,500.0013%
- Out-of-pocket maximum
- $317.84 of $3,000.0011%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9577388835
- Network
- In network
- Rendering NPI
- 5879285331
- Location
- San Diego, CA · TIN 59-7978167
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $86.00 | $53.32 | $25.00 | $28.32 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $332.00 | $205.84 | $0.00 | $205.84 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | 25 | 1 | 2 | $82.00 | $50.84 | $0.00 | $50.84 | Paid |
| Totals | $500.00 | $310.00 | $25.00 | $285.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-883968
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001850 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-29: OPTIONS-PPO (PPO), effective 2021-07-01, terms 2026-03-24. | |
| Timely filing | Pass | Received 38 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 (9577388835). | |
| 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 Associates2025-11-29 13:15
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009522 | 2025-12-28 | Sunrise Community Hospital | $2,133.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.