CLM-2026-016755
Meadow Medical Group, Family Medicine. Service 2026-08-25 at office (POS 11). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- James Williams
- Member ID
- UHC-59391-53
- Date of birth
- 1985-08-22
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-422097
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3909
- Coverage period
- 2024-08-01 to 2026-02-07
- Deductible
- $405.93 of $1,500.0027%
- Out-of-pocket maximum
- $965.31 of $3,000.0032%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7358617562
- Network
- In network
- Rendering NPI
- 5943815733
- Location
- Tempe, AZ · TIN 28-5097821
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $205.00 | $127.10 | — | — | DeniedCO27 |
| 2 | 90471 | Immunization administration | — | 1 | 2 | $27.00 | $16.74 | — | — | DeniedCO27 |
| Totals | $232.00 | $143.84 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-325876
- 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-028855 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-25 is after coverage terminated on 2026-02-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 Medical Group (7358617562). | |
| 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 Medical Group2026-08-25 15:09
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-30 03:00
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-30 08:26
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 13:43Eligibility: Date of service 2026-08-25 is after coverage terminated on 2026-02-07.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017284 | 2026-03-25 | Sunrise Medical Group | $386.00 | Denied |
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.