CLM-2026-027968
Meadow GI Associates, Gastroenterology. Service 2026-04-13 at office (POS 11). Received 2026-04-16.
Member
Resolved through the identity graph
- Member
- Debra Cox
- Member ID
- UHC-62132-15
- Date of birth
- 1993-06-22
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-419411
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3717
- Coverage period
- 2022-10-01 to present
- Deductible
- $16.84 of $1,000.002%
- Out-of-pocket maximum
- $469.79 of $2,000.0023%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 2683250932
- Location
- Los Angeles, CA · TIN 16-0400328
- Authorisation / referral
- none / REF251403
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 | $256.00 | $115.20 | — | — | DeniedCO204 |
| Totals | $256.00 | $115.20 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-103382
- 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-019798 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-13: CORE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 3 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 | Fail | CO204 | Billing provider 7747243401 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 GI Associates2026-04-13 09:29
Patient seen for epigastric pain.
- SystemSystem: Claims system2026-04-16 06:55
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 7747243401 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032045 | 2026-07-18 | Canyon Cardiovascular Associates | $1,506.00 | Denied |
| CLM-2026-006255 | 2026-03-13 | Cornerstone Bone and Joint Center | $10,312.00 | 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
No out-of-network benefit on this plan.