CLM-2026-031856
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-08-24 at office (POS 11). Received 2026-10-20.
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 | — | — | DeniedCO18 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $79.00 | $48.98 | — | — | DeniedCO18 |
| Totals | $124.00 | $76.88 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- 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, 1 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 57 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-031855: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Associates2026-08-24 18:10
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-20 03:39
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-20 16:35
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-031855: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| 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-2026-031855 | 2026-08-24 | Mesa Internal Medicine Associates | $124.00 | Approved |
| CLM-2026-002369 | 2026-02-16 | Lakeside Physical Therapy | $198.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.