CLM-2026-009750
Meadow Primary Care Associates, Family Medicine. Service 2026-06-22 at office (POS 11). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Jerry Crawford
- Member ID
- UHC-60376-73
- Date of birth
- 1980-07-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408863
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6614
- Coverage period
- 2025-10-01 to present
- Deductible
- $728.92 of $1,500.0049%
- Out-of-pocket maximum
- $537.05 of $4,500.0012%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2034376493
- Network
- In network
- Rendering NPI
- 6631733626
- Location
- Phoenix, AZ · TIN 89-2669492
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $168.00 | $104.16 | — | — | DeniedCO29 |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $20.00 | $12.40 | — | — | DeniedCO29 |
| Totals | $188.00 | $116.56 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-437561
- 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-039071 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-22: OPTIONS-PPO (PPO), effective 2025-10-01. | |
| Timely filing | Fail | CO29 | Received 99 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 Primary Care Associates (2034376493). | |
| 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 Primary Care Associates2026-06-22 13:44
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-29 06:08
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-29 17:20
Member services inquiry logged on this claim; member asked about the status of payment.
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 99 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030088 | 2026-07-12 | Valley Imaging Center | $1,668.00 | Approved |
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.