Professional claim · CMS-1500 · Provider portal
CLM-2026-029692
Meadow Medical Group, Family Medicine. Service 2026-01-24 at office (POS 11). Received 2026-03-04.
Approved
Billed
$226.00
1 line
Allowed
$140.12
contract rate applied
Plan pays
$115.12
approved
Member owes
$25.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Maria Meyer
- Member ID
- UHC-73025-52
- Date of birth
- 1957-11-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416206
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6844
- Coverage period
- 2024-02-01 to present
- Deductible
- $367.66 of $1,000.0037%
- Out-of-pocket maximum
- $856.56 of $4,000.0021%
- Copays
- office $25.00, specialist $40.00, 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
- 7059608472
- 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 | $226.00 | $140.12 | $25.00 | $115.12 | Paid |
| Totals | $226.00 | $140.12 | $25.00 | $115.12 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-749972
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001540 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-24: SELECT-EPO (EPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 39 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Medical Group2026-01-24 13:33
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$226.00
Plan discount
$85.88
contracted rate
Plan paid
$115.12
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002340 | 2026-02-07 | Cornerstone Bone and Joint Center | $11,725.00 | Approved |
| CLM-2026-005011 | 2025-11-21 | Summit Regional Medical Center | $3,280.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.