CLM-2026-033156
Meadow Internal Medicine Associates, Internal Medicine. Service 2026-01-30 to 2026-02-02 at inpatient hospital (POS 21). Received 2026-02-21.
Member
Resolved through the identity graph
- Member
- Kayla Franklin
- Member ID
- UHC-54119-79
- Date of birth
- 1997-12-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-406288
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0345
- Coverage period
- 2022-05-01 to 2026-01-11
- Deductible
- $1,166.76 of $1,500.0078%
- Out-of-pocket maximum
- $892.08 of $6,000.0015%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1151313396
- Network
- In network
- Rendering NPI
- 9089141292
- Location
- Phoenix, AZ · TIN 41-0387297
- Authorisation / referral
- none / 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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $196.00 | $107.80 | — | — | DeniedCO27 |
| Totals | $196.00 | $107.80 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-926266
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-30 to 2026-02-03
- 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-014868 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-01-30 is after coverage terminated on 2026-01-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 19 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 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 Associates2026-02-02 17:36
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-02-21 04:57
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-21 17:14
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-926266.pdf5 pages
Itemised statement totalling $196.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-01-30 is after coverage terminated on 2026-01-11.
Other claims for this member
Same resolved identity
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.