Claims workbench/CLM-2026-008873
Professional claim · CMS-1500 · EDI 837P

CLM-2026-008873

Meadow Medical Group, Family Medicine. Service 2026-08-15 at office (POS 11). Received 2026-08-23.

PendedIdentity on hold: CASE-004301
Billed
$193.00
1 line
Allowed
$119.66
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Samuel Tucker
Member ID
UHC-63335-10
Date of birth
1963-03-27
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-419466
Relationship
Self, Austin, TX

Coverage and accumulators

Found by member ID

Plan
NAVIGATE-HMO HMO group GRP-7154
Coverage period
2025-03-01 to present
Deductible
$2,494.58 of $3,500.0071%
Out-of-pocket maximum
$1,903.89 of $14,000.0014%
Copays
office $40.00, specialist $40.00, emergency $350.00
Physical therapy visits
20 of 20 used

Provider

Billing and rendering

Billing provider
Meadow Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
1969094295
Network
In network
Rendering NPI
5892080586
Location
Mesa, AZ · TIN 47-6962698
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199203Office visit, new patient, low complexity—11$193.00$119.66——PendedIDQ
Totals$193.00$119.66——
Diagnoses (ICD-10-CM)
  • 1. E78.5 Hyperlipidemia, unspecifiedprincipal
  • 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
Patient account
PA-226834
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-004301; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-08-15: NAVIGATE-HMO (HMO), effective 2025-03-01.
Timely filingPassReceived 8 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Meadow Medical Group (1969094295).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Meadow Medical Group2026-08-15 09:34

    Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-004301; payment withheld until the identity is confirmed.

Other claims for this member

Same resolved identity

No other claims.

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.

Review queueMember identity