CLM-2026-030636
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-07-05 to 2026-07-07 at inpatient hospital (POS 21). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Carl McCoy
- Member ID
- UHC-90578-64
- Date of birth
- 2008-07-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411515
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7591
- Coverage period
- 2023-12-01 to present
- Deductible
- $166.02 of $2,500.007%
- Out-of-pocket maximum
- $4,885.64 of $10,000.0049%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 4707375216
- Network
- In network
- Rendering NPI
- 9245847857
- Location
- Los Angeles, CA · TIN 98-0064995
- 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 | $183.00 | $100.65 | $100.65 | $0.00 | Paid |
| Totals | $183.00 | $100.65 | $100.65 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-358986
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-05 to 2026-07-08
- 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-023984 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-05: MEDICARE-ADV-A (MA), effective 2023-12-01. | |
| Timely filing | Pass | Received 42 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 | 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 Associates2026-07-07 16:39
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-358986.pdf7 pages
Itemised statement totalling $183.00 across 1 line.
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
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.