CLM-2026-000352
Meadow Family Practice, Family Medicine. Service 2026-07-04 at office (POS 11). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Abigail Hicks
- Member ID
- UHC-46842-79
- Date of birth
- 2001-04-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-407484
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2410
- Coverage period
- 2023-02-01 to 2026-02-04
- Deductible
- $2,839.23 of $3,500.0081%
- Out-of-pocket maximum
- $464.32 of $7,000.007%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6211464576
- Network
- In network
- Rendering NPI
- 1727301875
- Location
- Dallas, TX · TIN 25-4290712
- 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 | 90471 | Immunization administration | — | 1 | 1 | $33.00 | $20.46 | — | — | DeniedCO27 |
| Totals | $33.00 | $20.46 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-806467
- 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-011217 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-04 is after coverage terminated on 2026-02-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 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 Meadow Family Practice (6211464576). | |
| 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: Meadow Family Practice2026-07-04 10:20
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-15 02:28
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 2026-07-04 is after coverage terminated on 2026-02-04.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004741 | 2026-08-13 | Northgate Reference Lab | $143.00 | Denied |
| CLM-2026-017372 | 2026-04-09 | Lakeside Reference Lab | $68.00 | Denied |
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.