CLM-2026-033269
Meadow Primary Care Associates, Family Medicine. Service 2026-02-22 at office (POS 11). Received 2026-03-06.
Member
Resolved through the identity graph
- Member
- Patricia Garza
- Member ID
- UHC-24445-51
- Date of birth
- 1949-02-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-414424
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2473
- Coverage period
- 2022-01-01 to 2026-01-27
- Deductible
- $1,289.76 of $1,500.0086%
- Out-of-pocket maximum
- $464.69 of $4,500.0010%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 8748622841
- Network
- In network
- Rendering NPI
- 5759041770
- Location
- Atlanta, GA · TIN 43-6231425
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $207.00 | $128.34 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | 25 | 1 | 1,2 | $19.00 | $11.78 | — | — | DeniedCO27 |
| 3 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $214.00 | $132.68 | — | — | DeniedCO27 |
| Totals | $440.00 | $272.80 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-928467
- 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-017877 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-22 is after coverage terminated on 2026-01-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 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 Primary Care Associates (8748622841). | |
| 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 Primary Care Associates2026-02-22 14:23
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-06 03:37
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 2026-02-22 is after coverage terminated on 2026-01-27.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004012 | 2026-03-02 | Meadow Primary Care Associates | $315.00 | 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.