CLM-2026-029955
Meadow Family Practice, Family Medicine. Service 2026-08-19 at outpatient hospital (POS 22). Received 2026-09-12.
Member
Resolved through the identity graph
- Member
- Madison Jenkins
- Member ID
- UHC-28890-43
- Date of birth
- 1983-01-05
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-413822
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9272
- Coverage period
- 2022-11-01 to 2026-08-17
- Deductible
- $404.33 of $2,500.0016%
- Out-of-pocket maximum
- $4,437.73 of $10,000.0044%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8614941473
- Network
- In network
- Rendering NPI
- 5296993160
- Location
- Atlanta, GA · TIN 64-8981661
- Authorisation / referral
- PA2026144905 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,099.00 | $1,704.45 | — | — | DeniedCO27 |
| Totals | $3,099.00 | $1,704.45 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-337120
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040823 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-19 is after coverage terminated on 2026-08-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026144905 on file for 70553. | |
| Provider network | Pass | In-network provider Meadow Family Practice (8614941473). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Family Practice2026-08-19 12:44
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-09-12 01:52
Attachments
Documents received with the claim
- Prior auth letterPA2026144905_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-19 to 2026-11-17.
- Itemized billitemized_PA-337120.pdf5 pages
Itemised statement totalling $3099.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-19 is after coverage terminated on 2026-08-17. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001215 | 2026-09-11 | Northgate Clinical Laboratories | $76.00 | 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.