CLM-2026-033007
Mesa Internal Medicine Associates, Internal Medicine. Service 2026-08-01 at office (POS 11). Received 2026-08-24.
Member
Resolved through the identity graph
- Member
- Mariana Webb
- Member ID
- UHC-95353-72
- Date of birth
- 1981-01-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413968
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group N/A
- Coverage period
- 2021-08-01 to present
- Deductible
- $2,013.16 of $3,500.0058%
- Out-of-pocket maximum
- $2,564.69 of $10,500.0024%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1153640218
- Network
- In network
- Rendering NPI
- 1049003613
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $71.00 | $44.02 | $20.00 | $24.02 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $200.00 | $124.00 | $0.00 | $124.00 | Paid |
| Totals | $271.00 | $168.02 | $20.00 | $148.02 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-365202
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-008161 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-01: SELECT-EPO (EPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 23 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 Associates2026-08-01 17:13
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
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.