CLM-2026-004581
Meadow Primary Care Associates, Family Medicine. Service 2026-06-07 at office (POS 11). Received 2026-06-26.
Member
Resolved through the identity graph
- Member
- Doris Guzman
- Member ID
- UHC-56787-59
- Date of birth
- 1956-10-23
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-421587
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7067
- Coverage period
- 2024-01-01 to present
- Deductible
- $1,133.91 of $2,500.0045%
- Out-of-pocket maximum
- $1,992.32 of $10,000.0020%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8748622841
- Network
- In network
- Rendering NPI
- 3912007564
- Location
- Atlanta, GA · TIN 43-6231425
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $240.00 | $148.80 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $213.00 | $132.06 | — | — | Review |
| Totals | $453.00 | $280.86 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-818437
- 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-002577 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-07: MEDICARE-ADV-B (MA), effective 2024-01-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-004580, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow Primary Care Associates (8748622841). | |
| 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 Primary Care Associates2026-06-07 17:27
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-26 01:41
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-26 17:03
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-004580, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020351 | 2026-05-26 | Unity Medical Group | $179.00 | Approved |
| CLM-2026-004580 | 2026-06-07 | Harbor Primary Care Associates | $453.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.