CLM-2026-008411
Meadow Family Practice, Family Medicine. Service 2026-01-24 at office (POS 11). Received 2026-06-10.
Member
Resolved through the identity graph
- Member
- Christian Coleman
- Member ID
- UHC-66406-19
- Date of birth
- 2001-06-07
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-430973
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0513
- Coverage period
- 2022-07-01 to present
- Deductible
- $2,102.77 of $2,500.0084%
- Out-of-pocket maximum
- $1,579.02 of $5,000.0032%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1613403900
- Network
- In network
- Rendering NPI
- 3511194995
- Location
- Atlanta, GA · TIN 74-8679615
- 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 | $32.00 | $19.84 | — | — | DeniedCO29 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $192.00 | $119.04 | — | — | DeniedCO29 |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $149.00 | $92.38 | — | — | DeniedCO29 |
| Totals | $373.00 | $231.26 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-421702
- 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-011898 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-24: OPTIONS-PPO (PPO), effective 2022-07-01. | |
| Timely filing | Fail | CO29 | Received 137 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Family Practice (1613403900). | |
| 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 Family Practice2026-01-24 13:42
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-06-10 02:47
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-10 15:42
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 137 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.