CLM-2026-032376
Mesa GI Associates, Gastroenterology. Service 2026-10-01 at office (POS 11). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Wayne Diez
- Member ID
- UHC-82176-57
- Date of birth
- 1965-01-23
- Identity
- Verified2 records, confidence 0.98
- Claim record
- CLMCLM-409466
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4088
- Coverage period
- 2021-01-01 to 2026-08-13
- Deductible
- $3,019.24 of $3,500.0086%
- Out-of-pocket maximum
- $2,973.62 of $7,000.0042%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7557205672
- Network
- In network
- Rendering NPI
- 9145277536
- Location
- Phoenix, AZ · TIN 12-8480573
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $315.00 | $195.30 | — | — | DeniedCO27 |
| Totals | $315.00 | $195.30 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-243622
- 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-029394 (verified, link confidence 0.98). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-01 is after coverage terminated on 2026-08-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 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 GI Associates (7557205672). | |
| 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 GI Associates2026-10-01 17:57
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-11 05:55
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-10-01 is after coverage terminated on 2026-08-13.
Other claims for this member
Same resolved identity
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
Service after coverage termination.