CLM-2026-011987
Meadow Family Practice, Family Medicine. Service 2026-04-20 at office (POS 11). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Carol Murray
- Member ID
- UHC-75188-27
- Date of birth
- 1967-04-06
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-427192
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8207
- Coverage period
- 2021-10-01 to present
- Deductible
- $497.24 of $3,500.0014%
- Out-of-pocket maximum
- $1,117.23 of $7,000.0016%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6211464576
- Network
- In network
- Rendering NPI
- 5634672328
- 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 | 90471 | Immunization administration | — | 1 | 1 | $43.00 | $26.66 | — | — | Review |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $295.00 | $182.90 | — | — | Review |
| Totals | $338.00 | $209.56 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-592367
- 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-030470 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-20: MEDICARE-ADV-A (MA), effective 2021-10-01. | |
| Timely filing | Pass | Received 23 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 | Review | CO16 | Documentation incomplete: “Patient seen for encounter for general adult medical examination without abnormal findings”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Family Practice2026-04-20 13:34
Patient seen for encounter for general adult medical examination without abnormal findings. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-13 02:07
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-13 16:52
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for encounter for general adult medical examination without abnormal findings”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022695 | 2026-06-15 | Heritage GI Associates | $213.00 | Approved |
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
Development letter outstanding.