Professional claim · CMS-1500 · EDI 837P
CLM-2026-019028
Meadow Family Practice, Family Medicine. Service 2026-05-02 at office (POS 11). Received 2026-05-20.
Denied
Billed
$27.00
1 line
Allowed
$16.74
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Wei Garza
- Member ID
- UHC-23414-25
- Date of birth
- 1952-02-20
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-402980
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4419
- Coverage period
- 2021-01-01 to 2026-03-08
- Deductible
- $1,068.74 of $3,500.0031%
- Out-of-pocket maximum
- $1,222.23 of $7,000.0017%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1613403900
- Network
- In network
- Rendering NPI
- 3401397377
- Location
- Atlanta, GA · TIN 74-8679615
- 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 | 90471 | Immunization administration | — | 1 | 1 | $27.00 | $16.74 | — | — | DeniedCO27 |
| Totals | $27.00 | $16.74 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-205766
- 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-016922 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-02 is after coverage terminated on 2026-03-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 18 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 Family Practice (1613403900). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Family Practice2026-05-02 15:35
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-05-20 03:22
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-02 is after coverage terminated on 2026-03-08.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.