CLM-2026-003429
Meadow Family Practice, Family Medicine. Service 2026-05-01 at office (POS 11). Received 2026-05-12.
Member
Resolved through the identity graph
- Member
- Carlos Young
- Member ID
- UHC-22068-37
- Date of birth
- 1958-03-14
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-418825
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9402
- Coverage period
- 2023-06-01 to present
- Deductible
- $15.26 of $1,000.002%
- Out-of-pocket maximum
- $367.89 of $3,000.0012%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1613403900
- Network
- In network
- Rendering NPI
- 2434995454
- Location
- Atlanta, GA · TIN 74-8679615
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $307.00 | $190.34 | — | — | DeniedCO18 |
| 2 | 90471 | Immunization administration | — | 1 | 1,2 | $35.00 | $21.70 | — | — | DeniedCO18 |
| Totals | $342.00 | $212.04 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-655952
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019054 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-01: CORE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-003428: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow Family Practice (1613403900). | |
| 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 Practice2026-05-01 18:08
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-05-12 02:41
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-12 12:14
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-003428: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003428 | 2026-05-01 | Meadow Family Practice | $342.00 | Approved |
| CLM-2026-004111 | 2026-03-09 | Northgate Heart Institute | $228.00 | Approved |
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
Exact duplicate of an earlier submission.