Claims workbench/CLM-2026-007161

Professional claim · CMS-1500 · EDI 837P

CLM-2026-007161

Meadow Primary Care Associates, Family Medicine. Service 2026-02-28 at office (POS 11). Received 2026-03-04.

Denied

Billed

$362.00

2 lines

Allowed

$224.44

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Jessica Adams
Member ID: UHC-97802-47
Date of birth: 1961-07-22
Identity: Verified7 records, confidence 0.99
Claim record: CLMCLM-418594
Relationship: Spouse, Columbus, OH

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-6200
Coverage period: 2021-06-01 to 2026-02-06
Deductible: $1,729.68 of $2,500.0069%
Out-of-pocket maximum: $816.54 of $10,000.008%
Copays: office $30.00, specialist $75.00, emergency $350.00
Physical therapy visits: 21 of 20 used

Provider

Billing and rendering

Billing provider: Meadow Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 9704343703
Network: In network
Rendering NPI: 5745525498
Location: Tampa, FL · TIN 74-5049309
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	$164.00	$101.68	—	—	DeniedCO27
2	99203	Office visit, new patient, low complexity	—	1	1,2	$198.00	$122.76	—	—	DeniedCO27
Totals						$362.00	$224.44	—	—

Diagnoses (ICD-10-CM)

1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
2. Z00.00 Encounter for general adult medical examination without abnormal findings

Claim header

Patient account: PA-331507
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-009046 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-02-28 is after coverage terminated on 2026-02-06. Expenses incurred after coverage terminated
Timely filing	Pass		Received 4 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 (9704343703).
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Meadow Primary Care Associates2026-02-28 18:27
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-03-04 05:52
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-04 08:05
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-02-28 is after coverage terminated on 2026-02-06.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-022404	2026-06-29	Harbor Cardiovascular Associates	$671.00	Denied
CLM-2026-018723	2026-03-26	Northgate Reference Lab	$164.00	Denied
CLM-2026-005799	2026-03-27	Northgate Orthopedic Specialists	$37,463.00	Denied
CLM-2026-025279	2026-01-19	Desert Internal Medicine Associates	$259.00	Needs review

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity