Professional claim · CMS-1500 · Paper
CLM-2026-007528
Meadow Primary Care Associates, Family Medicine. Service 2026-06-01 at office (POS 11). Received 2026-07-04.
Billed
$302.00
1 line
Allowed
$187.24
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Lawrence Alvarado
- Member ID
- none on golden record
- Date of birth
- 1956-02-11
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-418565
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-6076
- Coverage period
- 2022-10-01 to present
- Deductible
- $317.68 of $500.0064%
- Out-of-pocket maximum
- $395.75 of $2,000.0020%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8748622841
- Network
- In network
- Rendering NPI
- 1095510800
- Location
- Atlanta, GA · TIN 43-6231425
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $302.00 | $187.24 | — | — | PendedIDQ |
| Totals | $302.00 | $187.24 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-132951
- 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-001920; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-06-01: MEDICARE-ADV-A (MA), effective 2022-10-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 33 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 (8748622841). | |
| 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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Primary Care Associates2026-06-01 16:29
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
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-001920; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-01: MEDICARE-ADV-A (MA), effective 2022-10-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007529 | 2026-06-01 | Meadow Primary Care Associates | $302.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Outcome
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
Approvedscenario: Clean
Clean claim, priced at contract rate.