CLM-2026-003884
Meadow Medical Group, Family Medicine. Service 2026-09-12 at office (POS 11). Received 2026-10-06.
Member
Resolved through the identity graph
- Member
- Emily Bryant
- Member ID
- UHC-96529-14
- Date of birth
- 2003-02-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417324
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2202
- Coverage period
- 2021-11-01 to present
- Deductible
- $2,555.79 of $3,500.0073%
- Out-of-pocket maximum
- $2,939.32 of $10,500.0028%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1969094295
- Network
- In network
- Rendering NPI
- 7488954174
- Location
- Mesa, AZ · TIN 47-6962698
- 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 | $142.00 | $88.04 | $40.00 | $48.04 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $327.00 | $202.74 | $0.00 | $202.74 | Paid |
| 3 | 36415 | Venipuncture | — | 1 | 2 | $22.00 | $13.64 | $0.00 | $13.64 | Paid |
| Totals | $491.00 | $304.42 | $40.00 | $264.42 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-708217
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-045880 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-12: SELECT-EPO (EPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 24 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 Medical Group (1969094295). | |
| 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 Medical Group2026-09-12 10:42
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-10-06 05:14
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-06 16:09
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-708217.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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
Authorisation must be confirmed with UM before payment.