CLM-2026-009143
Meadow Family Practice, Family Medicine. Service 2026-04-20 at office (POS 11). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Ethan Arnold
- Member ID
- UHC-72887-01
- Date of birth
- 2005-02-01
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-403465
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-8012
- Coverage period
- 2022-03-01 to 2026-04-15
- Deductible
- $267.44 of $500.0053%
- Out-of-pocket maximum
- $229.11 of $1,000.0023%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6211464576
- Network
- In network
- Rendering NPI
- 4445222704
- Location
- Dallas, TX · TIN 25-4290712
- 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 | $185.00 | $114.70 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $17.00 | $10.54 | — | — | DeniedCO27 |
| Totals | $202.00 | $125.24 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-628860
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024986 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-20 is after coverage terminated on 2026-04-15. Expenses incurred after coverage terminated |
| 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 Family Practice (6211464576). | |
| 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 Practice2026-04-20 15:14
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-23 02:58
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-23 10:11
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-20 is after coverage terminated on 2026-04-15.
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
Service after coverage termination.