CLM-2026-031216
Meadow Medical Group, Family Medicine. Service 2026-04-03 at office (POS 11). Received 2026-05-16.
Member
Resolved through the identity graph
- Member
- Peter Reyes
- Member ID
- UHC-30205-67
- Date of birth
- 1944-10-12
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-419977
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group NULL
- Coverage period
- 2021-02-01 to 2026-08-25
- Deductible
- $1,323.88 of $1,500.0088%
- Out-of-pocket maximum
- $251.10 of $3,000.008%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7358617562
- Network
- In network
- Rendering NPI
- 1781670314
- Location
- Tempe, AZ · TIN 28-5097821
- 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 | 36415 | Venipuncture | — | 1 | 1 | $24.00 | $14.88 | $14.88 | $0.00 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $39.00 | $24.18 | $0.00 | $24.18 | Paid |
| Totals | $63.00 | $39.06 | $14.88 | $24.18 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-811062
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030941 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-03: N/A (PPO), effective 2021-02-01, terms 2026-08-25. | |
| Timely filing | Pass | Received 43 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 (7358617562). | |
| 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 Group2026-04-03 09:45
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-16 04:35
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-811062.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.