CLM-2026-017536
Meadow Medical Group, Family Medicine. Service 2025-08-01 at office (POS 11). Received 2026-02-04.
Member
Resolved through the identity graph
- Member
- Kevin Burke
- Member ID
- none on golden record
- Date of birth
- 1985-11-22
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-421920
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6898
- Coverage period
- 2025-01-01 to present
- Deductible
- $434.34 of $1,000.0043%
- Out-of-pocket maximum
- $948.91 of $3,000.0032%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1969094295
- Network
- In network
- Rendering NPI
- 8136242111
- Location
- Mesa, AZ · TIN 47-6962698
- 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 | $167.00 | $103.54 | — | — | DeniedCO29 |
| Totals | $167.00 | $103.54 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-154172
- 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-000868; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-08-01: CHOICE-PLUS-PPO (PPO), effective 2025-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Fail | CO29 | Received 187 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (1969094295). | |
| 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 Group2025-08-01 12:38
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-02-04 02:52
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-000868; payment withheld until the identity is confirmed. Eligibility: Active on 2025-08-01: CHOICE-PLUS-PPO (PPO), effective 2025-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. Timely filing: Received 187 days after the last date of service (limit 90).
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
Received after the timely-filing limit.