CLM-2026-024721
Meadow Primary Care Associates, Family Medicine. Service 2026-07-16 at office (POS 11). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Sandra Fuller
- Member ID
- UHC-21692-45
- Date of birth
- 1983-09-17
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-404072
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6488
- Coverage period
- 2025-02-01 to present
- Deductible
- $17.00 of $500.003%
- Out-of-pocket maximum
- $84.22 of $1,500.006%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 5061732918
- Network
- In network
- Rendering NPI
- 6779998668
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $202.00 | $125.24 | $40.00 | $85.24 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 1 | $224.00 | $138.88 | $0.00 | $138.88 | Paid |
| Totals | $426.00 | $264.12 | $40.00 | $224.12 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-141370
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011174 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-16: CHOICE-PLUS-PPO (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 22 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 Associates2026-07-16 15:59
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017498 | 2026-06-28 | Cornerstone Internal Medicine Associates | $371.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.