CLM-2026-001138
Meadow Family Practice, Family Medicine. Service 2025-07-09 at office (POS 11). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Janice Ellis
- Member ID
- UHC-61445-16
- Date of birth
- —
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406286
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6216
- Coverage period
- 2023-07-01 to present
- Deductible
- $2,111.42 of $3,500.0060%
- Out-of-pocket maximum
- $2,960.65 of $10,500.0028%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8614941473
- Network
- In network
- Rendering NPI
- 3810598235
- Location
- Atlanta, GA · TIN 64-8981661
- 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 | 36415 | Venipuncture | — | 1 | 1 | $14.00 | $8.68 | — | — | DeniedCO29 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $293.00 | $181.66 | — | — | DeniedCO29 |
| Totals | $307.00 | $190.34 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-680321
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000896; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2025-07-09: SELECT-EPO (EPO), effective 2023-07-01. | |
| Timely filing | Fail | CO29 | Received 185 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (8614941473). | |
| 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 Practice2025-07-09 16:51
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-01-10 01:37
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-000896; payment withheld until the identity is confirmed. Timely filing: Received 185 days after the last date of service (limit 90).
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
Received after the timely-filing limit.