CLM-2026-031809
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-01-25 to 2026-01-27 at inpatient hospital (POS 21). Received 2026-02-17.
Member
Resolved through the identity graph
- Member
- Thomas Sanchez
- Member ID
- UHC-02366-75
- Date of birth
- 1943-03-28
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-424998
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4262
- Coverage period
- 2024-08-01 to present
- Deductible
- $2,125.01 of $3,500.0061%
- Out-of-pocket maximum
- $2,474.82 of $7,000.0035%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1153640218
- Network
- In network
- Rendering NPI
- 8886686624
- Location
- Houston, TX · TIN 60-7207391
- 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 | $251.00 | $138.05 | $138.05 | $0.00 | Paid |
| Totals | $251.00 | $138.05 | $138.05 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-421134
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-25 to 2026-01-26
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006735 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-25: MEDICARE-ADV-B (MA), effective 2024-08-01. | |
| Timely filing | Pass | Received 21 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 (1153640218). | |
| 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 Associates2026-01-27 13:40
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Itemized billitemized_PA-421134.pdf5 pages
Itemised statement totalling $251.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean 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.