CLM-2026-025722
Meadow GI Associates, Gastroenterology. Service 2026-02-21 at office (POS 11). Received 2026-03-21.
Member
Resolved through the identity graph
- Member
- Joshua Gibson
- Member ID
- UHC-44042-29
- Date of birth
- 1945-05-01
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416381
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8234
- Coverage period
- 2023-01-01 to present
- Deductible
- $327.44 of $500.0065%
- Out-of-pocket maximum
- $150.72 of $1,000.0015%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1813475971
- Network
- In network
- Rendering NPI
- 3524628765
- Location
- Austin, TX · TIN 38-1568789
- 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 | $274.00 | $169.88 | — | — | Review |
| Totals | $274.00 | $169.88 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-278308
- 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-018650 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-21: NULL (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 28 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 GI Associates (1813475971). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with gastro-esophageal reflux disease without esophagitis; sy”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow GI Associates2026-02-21 13:38
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-21 00:32
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-21 16:01
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with gastro-esophageal reflux disease without esophagitis; sy”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.