Professional claim · CMS-1500 · EDI 837P
CLM-2026-031855
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-08-24 at office (POS 11). Received 2026-09-29.
Approved
Billed
$124.00
2 lines
Allowed
$76.88
contract rate applied
Plan pays
$56.88
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Carol Fowler
- Member ID
- UHC-12538-47
- Date of birth
- 1995-04-09
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-413113
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7734
- Coverage period
- 2024-11-01 to present
- Deductible
- $203.69 of $500.0041%
- Out-of-pocket maximum
- $131.87 of $1,000.0013%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1153640218
- Network
- In network
- Rendering NPI
- 4766673659
- Location
- Houston, TX · TIN 60-7207391
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $45.00 | $27.90 | $20.00 | $7.90 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $79.00 | $48.98 | $0.00 | $48.98 | Paid |
| Totals | $124.00 | $76.88 | $20.00 | $56.88 | ||||||
Diagnoses (ICD-10-CM)
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-445392
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-018557 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-24: MEDICARE-ADV-A (MA), effective 2024-11-01. | |
| Timely filing | Pass | Received 36 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Internal Medicine Associates2026-08-24 17:46
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$124.00
Plan discount
$47.12
contracted rate
Plan paid
$56.88
You may owe
$20.00
copay, deductible and coinsurance
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031856 | 2026-08-24 | Mesa Internal Medicine Associates | $124.00 | Denied |
| CLM-2026-000819 | 2026-09-26 | Pinecrest Internal Medicine Associates | $344.00 | Denied |
| CLM-2026-006441 | 2026-09-26 | Evergreen Internal Medicine Associates | $3,146.00 | Needs review |
| CLM-2026-000818 | 2026-09-26 | Pinecrest Internal Medicine Associates | $344.00 | Approved |
| CLM-2026-002369 | 2026-02-16 | Lakeside Physical Therapy | $198.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.