CLM-2026-002353
Meadow Family Practice, Family Medicine. Service 2026-09-07 at office (POS 11). Received 2026-09-28.
Member
Resolved through the identity graph
- Member
- Janice Herrera
- Member ID
- UHC-91917-46
- Date of birth
- 1986-09-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-415023
- Relationship
- Child, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3803
- Coverage period
- 2023-02-01 to 2026-06-10
- Deductible
- $231.31 of $500.0046%
- Out-of-pocket maximum
- $250.45 of $1,000.0025%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5067162870
- Network
- In network
- Rendering NPI
- 2054787561
- Location
- Nashville, TN · TIN 66-6363148
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $209.00 | $129.58 | — | — | DeniedCO27 |
| Totals | $209.00 | $129.58 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-229803
- 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-037536 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-07 is after coverage terminated on 2026-06-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 (5067162870). | |
| 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 Practice2026-09-07 17:08
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-09-28 04:01
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-28 15:48
Called the provider office; awaiting documentation.
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 2026-09-07 is after coverage terminated on 2026-06-10.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022359 | 2026-06-19 | Sunrise Heart Institute | $449.00 | 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.