CLM-2026-007159
Meadow Primary Care Associates, Family Medicine. Service 2025-12-27 at office (POS 11). Received 2026-02-01.
Member
Resolved through the identity graph
- Member
- Christina Burke
- Member ID
- UHC-98836-19
- Date of birth
- 2004-05-26
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422811
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-8681
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,045.34 of $1,500.0070%
- Out-of-pocket maximum
- $886.66 of $4,500.0020%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2034376493
- Network
- In network
- Rendering NPI
- 1222532685
- Location
- Phoenix, AZ · TIN 89-2669492
- 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 | 36415 | Venipuncture | 59 | 1 | 1 | $21.00 | $13.02 | — | — | PendedIDQ |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 1 | $154.00 | $95.48 | — | — | PendedIDQ |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $304.00 | $188.48 | — | — | PendedIDQ |
| Totals | $479.00 | $296.98 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-280481
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002232; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2025-12-27: NULL (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 36 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 Primary Care Associates (2034376493). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Associates2025-12-27 10:59
Patient seen for hyperlipidemia, unspecified. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-02-01 06:30
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-280481.pdf17 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002232; payment withheld until the identity is confirmed. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
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
Modifier 59 supported: distinct anatomical site documented.