CLM-2026-028801
Meadow Medical Group, Family Medicine. Service 2026-08-03 at office (POS 11). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Raymond Hall
- Member ID
- UHC-66052-13
- Date of birth
- 1978-08-11
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-402017
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3953
- Coverage period
- 2025-09-01 to 2026-07-23
- Deductible
- $176.54 of $1,000.0018%
- Out-of-pocket maximum
- $1,381.79 of $3,000.0046%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1969094295
- Network
- In network
- Rendering NPI
- 6855546662
- Location
- Mesa, AZ · TIN 47-6962698
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $321.00 | $199.02 | — | — | DeniedCO27 |
| Totals | $321.00 | $199.02 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-406776
- 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-017165 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-03 is after coverage terminated on 2026-07-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 Medical Group (1969094295). | |
| 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 Medical Group2026-08-03 14:21
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-17 04:38
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-17 12:33
Escalated to nurse reviewer for clinical opinion.
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 2026-08-03 is after coverage terminated on 2026-07-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022170 | 2026-08-20 | Unity Digestive Health Center | $2,061.00 | Denied |
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.