CLM-2026-033232
Meadow Family Practice, Family Medicine. Service 2026-06-11 at office (POS 11). Received 2026-07-03.
Member
Resolved through the identity graph
- Member
- Daniel Marshall
- Member ID
- UHC-91743-60
- Date of birth
- 1940-12-06
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-428867
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3606
- Coverage period
- 2021-04-01 to 2026-06-10
- Deductible
- $622.29 of $1,500.0041%
- Out-of-pocket maximum
- $141.75 of $3,000.005%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 6211464576
- Network
- In network
- Rendering NPI
- 3951694728
- Location
- Dallas, TX · TIN 25-4290712
- 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 | — | — | DeniedCO27 |
| Totals | $24.00 | $14.88 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-674534
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007503 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-11 is after coverage terminated on 2026-06-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 (6211464576). | |
| 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 Practice2026-06-11 13:38
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-03 01:05
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-11 is after coverage terminated on 2026-06-10.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011833 | 2026-01-01 | Riverside Primary Care Associates | $456.00 | 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
Service after coverage termination.