CLM-2026-018601
Meadow Family Practice, Family Medicine. Service 2025-09-06 at office (POS 11). Received 2026-02-12.
Member
Resolved through the identity graph
- Member
- Justin Morgan
- Member ID
- UHC-81951-04
- Date of birth
- 1956-06-21
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-409273
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group N/A
- Coverage period
- 2022-01-01 to present
- Deductible
- $2,386.00 of $3,500.0068%
- Out-of-pocket maximum
- $494.35 of $10,500.005%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5067162870
- Network
- In network
- Rendering NPI
- 3937819597
- Location
- Nashville, TN · TIN 66-6363148
- 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 | $309.00 | $191.58 | — | — | DeniedCO29 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $194.00 | $120.28 | — | — | DeniedCO29 |
| Totals | $503.00 | $311.86 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-977916
- 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-012459 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-09-06: NULL (PPO), effective 2022-01-01. | |
| Timely filing | Fail | CO29 | Received 159 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 Family Practice (5067162870). | |
| 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 Family Practice2025-09-06 12:22
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-02-12 05:04
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-12 12:28
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 159 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033474 | 2026-01-12 | Canyon Internal Medicine Associates | $375.00 | Approved |
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.