CLM-2026-029379
Meadow Primary Care Associates, Family Medicine. Service 2026-04-15 at office (POS 11). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Wayne Santos
- Member ID
- UHC-74830-37
- Date of birth
- 1967-08-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-405999
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1031
- Coverage period
- 2021-04-01 to 2026-01-03
- Deductible
- $501.52 of $1,000.0050%
- Out-of-pocket maximum
- $84.52 of $3,000.003%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2034376493
- Network
- In network
- Rendering NPI
- 4386369332
- Location
- Phoenix, AZ · TIN 89-2669492
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $189.00 | $117.18 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | 25 | 1 | 1 | $308.00 | $190.96 | — | — | DeniedCO27 |
| Totals | $497.00 | $308.14 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-912205
- 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-001573 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-15 is after coverage terminated on 2026-01-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 34 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 (2034376493). | |
| 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 Associates2026-04-15 18:13
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-05-19 01:36
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 2026-04-15 is after coverage terminated on 2026-01-03.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016945 | 2026-05-30 | Pinecrest Primary Care Associates | $309.00 | Denied |
| CLM-2026-012588 | 2025-12-19 | Unity Diagnostic Imaging | $341.00 | 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
Service after coverage termination.