CLM-2026-024969
Meadow Family Practice, Family Medicine. Service 2025-10-11 at office (POS 11). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Fatima Espinoza
- Member ID
- UHC-85345-13
- Date of birth
- 1987-11-15
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-419337
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0425
- Coverage period
- 2021-09-01 to present
- Deductible
- $406.14 of $500.0081%
- Out-of-pocket maximum
- $367.35 of $2,000.0018%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5067162870
- Network
- In network
- Rendering NPI
- 5606233364
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $281.00 | $174.22 | — | — | DeniedCO29 |
| Totals | $281.00 | $174.22 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-704076
- 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-021476 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-10-11: OPTIONS-PPO (PPO), effective 2021-09-01. | |
| Timely filing | Fail | CO29 | Received 163 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Practice2025-10-11 18:42
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-03-23 03:52
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 163 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024489 | 2026-08-07 | Northgate Reference Lab | $151.00 | Denied |
| CLM-2026-004559 | 2026-07-13 | Mesa Clinical Laboratories | $50.00 | Approved |
| CLM-2026-024488 | 2026-08-07 | Northgate Reference Lab | $151.00 | 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
Received after the timely-filing limit.