CLM-2026-005181
Meadow Family Practice, Family Medicine. Service 2026-03-17 at office (POS 11). Received 2026-04-05.
Member
Resolved through the identity graph
- Member
- Albert Guzman
- Member ID
- UHC-34549-49
- Date of birth
- 1968-01-08
- Identity
- Verified2 records, confidence 0.94
- Claim record
- CLMCLM-411743
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group N/A
- Coverage period
- 2025-02-01 to 2026-04-21
- Deductible
- $342.80 of $1,000.0034%
- Out-of-pocket maximum
- $467.19 of $2,000.0023%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1613403900
- Network
- In network
- Rendering NPI
- 2318090380
- 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 | 90471 | Immunization administration | — | 1 | 1 | $43.00 | $26.66 | — | — | DeniedCO18 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $334.00 | $207.08 | — | — | DeniedCO18 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $202.00 | $125.24 | — | — | DeniedCO18 |
| Totals | $579.00 | $358.98 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-430567
- 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-022651 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-03-17: NULL (PPO), effective 2025-02-01, terms 2026-04-21. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-005180: 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 Practice2026-03-17 09:37
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-04-05 06:21
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
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-2026-005180: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005180 | 2026-03-17 | Meadow Family Practice | $579.00 | 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.