CLM-2026-013119
Meadow Primary Care Associates, Family Medicine. Service 2026-01-24 at office (POS 11). Received 2026-03-09.
Member
Resolved through the identity graph
- Member
- Robert Ramos
- Member ID
- UHC-34491-97
- Date of birth
- 1946-11-20
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-432551
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8910
- Coverage period
- 2023-03-01 to present
- Deductible
- $1,809.21 of $2,500.0072%
- Out-of-pocket maximum
- $1,543.85 of $5,000.0031%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8748622841
- Network
- In network
- Rendering NPI
- 8330683441
- Location
- Atlanta, GA · TIN 43-6231425
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $261.00 | $161.82 | $25.00 | $136.82 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1,2 | $215.00 | $133.30 | $0.00 | $133.30 | Paid |
| Totals | $476.00 | $295.12 | $25.00 | $270.12 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-168043
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017572 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-24: OPTIONS-PPO (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 44 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 (8748622841). | |
| 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 Associates2026-01-24 11:55
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.