CLM-2026-024240
Meadow Family Practice, Family Medicine. Service 2026-07-28 at office (POS 11). Received 2026-08-16.
Member
Resolved through the identity graph
- Member
- Gabriel Lane
- Member ID
- UHC-54367-09
- Date of birth
- 1997-11-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-401129
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8484
- Coverage period
- 2021-12-01 to 2026-04-11
- Deductible
- $1,908.92 of $3,500.0055%
- Out-of-pocket maximum
- $786.69 of $14,000.006%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5067162870
- Network
- In network
- Rendering NPI
- 3185990454
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $268.00 | $166.16 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $148.00 | $91.76 | — | — | DeniedCO27 |
| Totals | $416.00 | $257.92 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-283295
- 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-028153 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-28 is after coverage terminated on 2026-04-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 19 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 (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 Practice2026-07-28 13:29
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-16 04:13
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-16 10:01
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 12:44Eligibility: Date of service 2026-07-28 is after coverage terminated on 2026-04-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008802 | 2026-03-15 | Meadow Medical Group | $202.00 | 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
Service after coverage termination.