Claims workbench/CLM-2026-024947
Professional claim · CMS-1500 · EDI 837P

CLM-2026-024947

Meadow Medical Group, Family Medicine. Service 2026-01-03 at office (POS 11). Received 2026-02-10.

PendedIdentity on hold: CASE-002651
Billed
$224.00
1 line
Allowed
$138.88
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Emily Sullivan
Member ID
UHC-29259-60
Date of birth
1940-08-05
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-428013
Relationship
Child

Coverage and accumulators

Found by member ID

Plan
NULL PPO group GRP-7829
Coverage period
2025-08-01 to 2026-05-05
Deductible
$2,571.62 of $3,500.0073%
Out-of-pocket maximum
$5,878.76 of $14,000.0042%
Copays
office $25.00, specialist $75.00, emergency $350.00
Physical therapy visits
10 of 20 used

Provider

Billing and rendering

Billing provider
Meadow Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
7358617562
Network
In network
Rendering NPI
5864111559
Location
Tempe, AZ · TIN 28-5097821
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199203Office visit, new patient, low complexity—11$224.00$138.88——PendedIDQ
Totals$224.00$138.88——
Diagnoses (ICD-10-CM)
  • 1. M54.50 Low back pain, unspecifiedprincipal
  • 2. E78.5 Hyperlipidemia, unspecified
Claim header
Patient account
PA-756296
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-002651; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-01-03: NULL (PPO), effective 2025-08-01, terms 2026-05-05.
Timely filingPassReceived 38 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Meadow Medical Group (7358617562).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Meadow Medical Group2026-01-03 15:44

    Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-002651; payment withheld until the identity is confirmed.

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

Record the final decision; pricing and remittance reasons follow from it

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.

Review queueMember identity