CLM-2026-020532
Meadow Primary Care Associates, Family Medicine. Service 2026-03-16 at office (POS 11). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Patricia Marshall
- Member ID
- UHC-92316-19
- Date of birth
- 1981-06-08
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-422997
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1390
- Coverage period
- 2022-10-01 to 2026-01-26
- Deductible
- $2,891.10 of $3,500.0083%
- Out-of-pocket maximum
- $2,827.87 of $10,500.0027%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 5061732918
- Network
- In network
- Rendering NPI
- 6648816521
- Location
- Scottsdale, AZ · TIN 54-2819857
- 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 | 36415 | Venipuncture | — | 1 | 1 | $16.00 | $9.92 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $160.00 | $99.20 | — | — | DeniedCO27 |
| Totals | $176.00 | $109.12 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-586974
- 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-006322 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-16 is after coverage terminated on 2026-01-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 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 Primary Care Associates (5061732918). | |
| 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 Primary Care Associates2026-03-16 09:58
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-30 00:25
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 2026-03-16 is after coverage terminated on 2026-01-26.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010928 | 2026-07-09 | Mesa Family Practice | $431.00 | Denied |
| CLM-2026-031425 | 2026-06-03 | Meadow Regional Medical Center | $1,102.00 | Denied |
| CLM-2026-005832 | 2026-02-03 | Unity Reference Lab | $180.00 | 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.