CLM-2026-010275
Meadow Family Practice, Family Medicine. Service 2026-06-08 at office (POS 11). Received 2026-07-12.
Member
Resolved through the identity graph
- Member
- Olivia Perez
- Member ID
- none on golden record
- Date of birth
- 1963-04-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415561
- Relationship
- Child, Las Vegas, NV
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-4040
- Coverage period
- 2024-10-01 to 2026-05-05
- Deductible
- $633.06 of $3,500.0018%
- Out-of-pocket maximum
- $1,918.56 of $7,000.0027%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6211464576
- Network
- In network
- Rendering NPI
- 6205608956
- 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 | $190.00 | $117.80 | — | — | DeniedCO27 |
| Totals | $190.00 | $117.80 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-321536
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000664; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-06-08 is after coverage terminated on 2026-05-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 34 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 Practice2026-06-08 16:51
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-12 02:54
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-12 08:29
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 13:43Member identity: Member record is in open steward case CASE-000664; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-06-08 is after coverage terminated on 2026-05-05.
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.