Professional claim · CMS-1500 · Provider portal
CLM-2026-007898
Meadow Primary Care Associates, Family Medicine. Service 2026-04-28 at office (POS 11). Received 2026-06-09.
Approved
Billed
$335.00
2 lines
Allowed
$207.70
contract rate applied
Plan pays
$181.04
approved
Member owes
$26.66
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Debra Le
- Member ID
- none on golden record
- Date of birth
- 1951-05-14
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-412396
- Relationship
- Child, Plano, TX
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-8082
- Coverage period
- 2025-02-01 to present
- Deductible
- $1,058.12 of $1,500.0071%
- Out-of-pocket maximum
- $1,150.98 of $3,000.0038%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 5061732918
- Network
- In network
- Rendering NPI
- 6450432805
- Location
- Scottsdale, AZ · TIN 54-2819857
- 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 | 90471 | Immunization administration | — | 1 | 1 | $43.00 | $26.66 | $26.66 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $292.00 | $181.04 | $0.00 | $181.04 | Paid |
| Totals | $335.00 | $207.70 | $26.66 | $181.04 | ||||||
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-422293
- 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-034260 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-04-28: MEDICARE-ADV-B (MA), effective 2025-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 42 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 (5061732918). | |
| 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. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Primary Care Associates2026-04-28 17:24
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$335.00
Plan discount
$127.30
contracted rate
Plan paid
$181.04
You may owe
$26.66
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Eligibility: Active on 2026-04-28: MEDICARE-ADV-B (MA), effective 2025-02-01. 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-2026-012536 | 2026-09-20 | Sunrise Community Hospital | $477.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
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.