CLM-2026-014887
Meadow GI Associates, Gastroenterology. Service 2026-06-12 at office (POS 11). Received 2026-07-17.
Member
Resolved through the identity graph
- Member
- Matthew Li
- Member ID
- UHC-56603-65
- Date of birth
- 1954-11-22
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-416520
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-3207
- Coverage period
- 2021-02-01 to 2026-03-09
- Deductible
- $1,020.02 of $3,500.0029%
- Out-of-pocket maximum
- $325.38 of $14,000.002%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 9757629487
- Location
- Los Angeles, CA · TIN 16-0400328
- 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 | $267.00 | $120.15 | — | — | DeniedCO27 |
| Totals | $267.00 | $120.15 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-255944
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004681 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-12 is after coverage terminated on 2026-03-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 GI Associates2026-06-12 13:08
Patient seen for irritable bowel syndrome with diarrhea.
- SystemSystem: Claims system2026-07-17 04:40
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-17 11:10
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-12 is after coverage terminated on 2026-03-09. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.