CLM-2026-010716
Meadow Primary Care Associates, Family Medicine. Service 2026-05-27 at office (POS 11). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Bobby Gray
- Member ID
- none on golden record
- Date of birth
- 1998-12-27
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-408977
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-5988
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,312.05 of $3,500.0037%
- Out-of-pocket maximum
- $4,735.05 of $14,000.0034%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2034376493
- Network
- In network
- Rendering NPI
- 1017293469
- 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 | 90471 | Immunization administration | 59 | 1 | 1 | $38.00 | $23.56 | — | — | PendedIDQ |
| 2 | 36415 | Venipuncture | 59 | 1 | 2 | $16.00 | $9.92 | — | — | PendedIDQ |
| 3 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $186.00 | $115.32 | — | — | PendedIDQ |
| Totals | $240.00 | $148.80 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-784860
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001627; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-27: OPTIONS-PPO (PPO), effective 2022-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 41 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 Primary Care Associates (2034376493). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Associates2026-05-27 15:26
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-07-07 00:26
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-07 08:38
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Medical recordrecords_PA-784860.pdf21 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001627; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-27: OPTIONS-PPO (PPO), effective 2022-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.