CLM-2026-028356
Meadow Internal Medicine Associates, Internal Medicine. Service 2026-06-12 at office (POS 11). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Megan Carpenter
- Member ID
- UHC-78670-63
- Date of birth
- 1946-06-01
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-410867
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9192
- Coverage period
- 2023-07-01 to 2026-03-27
- Deductible
- $1,206.83 of $3,500.0034%
- Out-of-pocket maximum
- $3,273.83 of $14,000.0023%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1151313396
- Network
- In network
- Rendering NPI
- 5904965139
- Location
- Phoenix, AZ · TIN 41-0387297
- Authorisation / referral
- none / REF209955
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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $70.00 | $43.40 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $248.00 | $153.76 | — | — | DeniedCO27 |
| Totals | $318.00 | $197.16 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-593151
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032555 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-12 is after coverage terminated on 2026-03-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 25 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 Internal Medicine Associates (1151313396). | |
| 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 Internal Medicine Associates2026-06-12 10:29
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-07 03:13
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-07 08:26
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 12:44Eligibility: Date of service 2026-06-12 is after coverage terminated on 2026-03-27.
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.