CLM-2026-031402
Meadow Internal Medicine Associates, Internal Medicine. Service 2026-05-14 at office (POS 11). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Heather Freeman
- Member ID
- UHC-21700-64
- Date of birth
- 2004-06-07
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408188
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group N/A
- Coverage period
- 2024-01-01 to present
- Deductible
- $813.31 of $1,500.0054%
- Out-of-pocket maximum
- $1,775.77 of $6,000.0030%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1151313396
- Network
- In network
- Rendering NPI
- 4898987522
- Location
- Phoenix, AZ · TIN 41-0387297
- Authorisation / referral
- none / REF221046
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 | $292.00 | $181.04 | — | — | DeniedCO18 |
| Totals | $292.00 | $181.04 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-417999
- 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-031135 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-14: NAVIGATE-HMO (HMO), effective 2024-01-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-031401: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow Internal Medicine Associates (1151313396). | |
| 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 Internal Medicine Associates2026-05-14 17:08
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-04 00:07
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-04 09:30
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 12:44Duplicate check: Exact duplicate of CLM-2026-031401: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001859 | 2026-04-10 | Heritage Medical Group | $163.00 | Approved |
| CLM-2026-031401 | 2026-05-14 | Meadow Internal Medicine Associates | $292.00 | 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
Exact duplicate of an earlier submission.