CLM-2026-007320
Meadow Medical Group, Family Medicine. Service 2026-07-01 at office (POS 11). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Beverly Cruz
- Member ID
- UHC-18244-83
- Date of birth
- 1984-09-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-404261
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7415
- Coverage period
- 2023-02-01 to present
- Deductible
- $665.35 of $1,000.0067%
- Out-of-pocket maximum
- $1,260.05 of $3,000.0042%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1969094295
- Network
- In network
- Rendering NPI
- 1994918450
- Location
- Mesa, AZ · TIN 47-6962698
- 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 | $205.00 | $127.10 | — | — | DeniedCO18 |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 1,2 | $158.00 | $97.96 | — | — | DeniedCO18 |
| Totals | $363.00 | $225.06 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-426347
- 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-000487 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-01: MEDICARE-ADV-B (MA), effective 2023-02-01. | |
| Timely filing | Pass | Received 63 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-007319: 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 (1969094295). | |
| 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 Group2026-07-01 09:54
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-09-02 01:40
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-02 13:10
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 engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-007319: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020484 | 2026-09-05 | Harbor Diabetes Center | $290.00 | Approved |
| CLM-2026-007319 | 2026-07-01 | Meadow Medical Group | $363.00 | 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.