CLM-2026-033616
Mesa Medical Group, Internal Medicine. Service 2026-08-04 to 2026-08-05 at inpatient hospital (POS 21). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Charles McDonald
- Member ID
- UHC-75613-83
- Date of birth
- 1943-08-24
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-429688
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1087
- Coverage period
- 2025-02-01 to present
- Deductible
- $1,133.04 of $3,500.0032%
- Out-of-pocket maximum
- $5,121.63 of $14,000.0037%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9057332212
- Network
- In network
- Rendering NPI
- 5242146434
- Location
- San Diego, CA · TIN 98-1862745
- 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 | $229.00 | $125.95 | $125.95 | $0.00 | Paid |
| Totals | $229.00 | $125.95 | $125.95 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-659659
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-04 to 2026-08-06
- 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-008597 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-04: MEDICARE-ADV-A (MA), effective 2025-02-01. | |
| Timely filing | Pass | Received 15 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 Medical Group (9057332212). | |
| 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 Medical Group2026-08-05 14:11
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-659659.pdf8 pages
Itemised statement totalling $229.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015341 | 2026-06-28 | Northgate Counseling Center | $237.00 | Approved |
| CLM-2026-022899 | 2026-04-18 | Lakeside Internal Medicine Associates | $712.00 | Approved |
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.