CLM-2026-027130
Meadow Primary Care Associates, Family Medicine. Service 2026-05-31 at office (POS 11). Received 2026-07-10.
Member
Resolved through the identity graph
- Member
- Kelly Carroll
- Member ID
- UHC-69019-16
- Date of birth
- 1991-12-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-403819
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1671
- Coverage period
- 2023-02-01 to 2026-01-03
- Deductible
- $1,746.87 of $3,500.0050%
- Out-of-pocket maximum
- $1,389.68 of $7,000.0020%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8748622841
- Network
- In network
- Rendering NPI
- 1061592378
- Location
- Atlanta, GA · TIN 43-6231425
- 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 | $248.00 | $153.76 | — | — | DeniedCO27 |
| 2 | 90471 | Immunization administration | 25 | 1 | 1 | $28.00 | $17.36 | — | — | DeniedCO27 |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $239.00 | $148.18 | — | — | DeniedCO27 |
| Totals | $515.00 | $319.30 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-247927
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003065; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-05-31 is after coverage terminated on 2026-01-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 40 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 (8748622841). | |
| 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 Associates2026-05-31 13:12
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-10 01:54
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-10 10:14
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 12:44Member identity: Member record is in open steward case CASE-003065; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-05-31 is after coverage terminated on 2026-01-03.
Other claims for this member
Same resolved identity
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.