CLM-2026-005834
Meadow Medical Group, Family Medicine. Service 2026-05-24 at office (POS 11). Received 2026-07-11.
Member
Resolved through the identity graph
- Member
- Rachel Hart
- Member ID
- UHC-02912-42
- Date of birth
- 1963-10-16
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-403356
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1043
- Coverage period
- 2023-08-01 to present
- Deductible
- $35.46 of $500.007%
- Out-of-pocket maximum
- $627.73 of $2,000.0031%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7358617562
- Network
- In network
- Rendering NPI
- 6613877532
- Location
- Tempe, AZ · TIN 28-5097821
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $192.00 | $119.04 | — | — | DeniedCO18 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $284.00 | $176.08 | — | — | DeniedCO18 |
| Totals | $476.00 | $295.12 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-453610
- 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-029325 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-24: NAVIGATE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 48 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-005833: 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 Medical Group (7358617562). | |
| 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 Group2026-05-24 10:26
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-07-11 02:17
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-11 13:40
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-005833: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033805 | 2026-09-05 | Harbor Endocrine Associates | $358.00 | Approved |
| CLM-2026-005833 | 2026-05-24 | Meadow Medical Group | $476.00 | 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.