CLM-2026-017663
Meadow Medical Group, Internal Medicine. Service 2026-08-24 at office (POS 11). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Christopher Russell
- Member ID
- UHC-40318-84
- Date of birth
- 1958-05-19
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-420652
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- - PPO group NULL
- Coverage period
- 2021-04-01 to present
- Deductible
- $596.17 of $1,000.0060%
- Out-of-pocket maximum
- $237.99 of $2,000.0012%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3950077545
- Network
- In network
- Rendering NPI
- 2492615358
- Location
- Denver, CO · TIN 15-9022901
- 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 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1 | $379.00 | $234.98 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1 | $61.00 | $37.82 | — | — | Review |
| Totals | $440.00 | $272.80 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-557989
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009206 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-24: - (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 2 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 (3950077545). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2026-08-24 11:48
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-08-26 06:14
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-26 12:19
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Medical recordrecords_PA-557989.pdf17 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022306 | 2026-05-12 | Harbor Digestive Health Center | $1,950.00 | Denied |
| CLM-2026-022305 | 2026-05-12 | Harbor Digestive Health Center | $1,950.00 | 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
Bundled code pair; modifier 59 not supported by the operative note.