Professional claim · CMS-1500 · Provider portal
CLM-2026-020592
Meadow Primary Care Associates, Family Medicine. Service 2026-02-17 at office (POS 11). Received 2026-03-26.
Approved
Billed
$589.00
3 lines
Allowed
$365.18
contract rate applied
Plan pays
$355.26
approved
Member owes
$9.92
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Isabella Griffin
- Member ID
- UHC-44529-74
- Date of birth
- 1958-12-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403595
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1013
- Coverage period
- 2025-12-01 to present
- Deductible
- $2,120.08 of $3,500.0061%
- Out-of-pocket maximum
- $1,933.46 of $10,500.0018%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 5061732918
- Network
- In network
- Rendering NPI
- 1726594512
- 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 | $9.92 | $0.00 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $290.00 | $179.80 | $0.00 | $179.80 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $283.00 | $175.46 | $0.00 | $175.46 | Paid |
| Totals | $589.00 | $365.18 | $9.92 | $355.26 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
- Patient account
- PA-540291
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004074 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-17: NAVIGATE-HMO (HMO), effective 2025-12-01. | |
| Timely filing | Pass | Received 37 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Primary Care Associates2026-02-17 13:03
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$589.00
Plan discount
$223.82
contracted rate
Plan paid
$355.26
You may owe
$9.92
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002960 | 2026-02-10 | Desert Primary Care Associates | $255.00 | Approved |
| CLM-2026-033260 | 2026-01-17 | Valley Regional Medical Center | $3,926.00 | Approved |
| CLM-2026-001005 | 2025-12-03 | Sunrise Cardiovascular Associates | $316.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved 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
Approvedscenario: Clean
Clean claim, priced at contract rate.