CLM-2026-031235
Meadow Family Practice, Family Medicine. Service 2026-05-10 at office (POS 11). Received 2026-05-30.
Member
Resolved through the identity graph
- Member
- Valentina Valdez
- Member ID
- UHC-40345-86
- Date of birth
- 1957-12-13
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417109
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5050
- Coverage period
- 2025-07-01 to 2026-01-17
- Deductible
- $1,337.25 of $1,500.0089%
- Out-of-pocket maximum
- $2,937.31 of $6,000.0049%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8614941473
- Network
- In network
- Rendering NPI
- 2137814606
- Location
- Atlanta, GA · TIN 64-8981661
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $280.00 | $173.60 | — | — | DeniedCO27 |
| Totals | $280.00 | $173.60 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-799527
- 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-032870 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-10 is after coverage terminated on 2026-01-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 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 Family Practice (8614941473). | |
| 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 Family Practice2026-05-10 14:35
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-05-30 03:44
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-30 16:18
Called the provider office; awaiting documentation.
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 2026-05-10 is after coverage terminated on 2026-01-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031695 | 2026-07-22 | Mesa GI Associates | $1,998.00 | 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.