Merid AI Example Workflow

Claim:: A 400 mg infliximab infusion and its two administration lines, given in the office at an Atlanta gastroenterology practice.
Medical Context:: Steroid‑dependent ileocolonic Crohn’s disease after a sixteen‑week azathioprine trial that failed at a therapeutic dose — and the plan authorised the infusion sixteen days before it was given.
Denial Reason:: Cobalt Bay Health Plan denied all three lines CO‑50, saying step‑therapy criteria were not established for this drug and diagnosis.

S1Triagewhat kind of problem this is
S2Strategywhich document, which clock
S3Criteriathe rule, at the version in force
S4Gap checkthe one question nobody can answer
S5Draftingthe letter, with its quotations
S6Cite‑checkevery sentence back to its source
S7Assemblepacket, exhibits, manifest
YouApproveyour biller, before anything is filed

Alvarez, M · Cobalt Bay Health Plan · DOS 18 Mar 2026 $1,649.04 in dispute · CO‑50 · appeal due 29 Sep 2026

What arrived7

What Merid found2

What Merid produced3

Health Insurance Claim Form (CMS-1500 02/12)Claim

Piedmont Digestive Health, PCSubmitted 21 Mar 2026837P · PCN2214

Boxes 1–13 · patient and insured

1a Insured’s ID CBH884120773 · 2 Alvarez, Marta R · 3 09 Mar 1991, F · 11 Group SPP‑PPO‑4471
12/13 Signature on file, 04 Jan 2026.

Boxes 21–23 · diagnosis and authorization

21.A K50.80 — Crohn’s disease of both small and large intestine, without complications.
23 Prior Authorization Number 0318‑CBH‑77421

Box 24 · service lines

Date	POS	Code	Mod	Units	Charges	Dx
03/18/26	11	J1745	JZ	40	$4,840.00	A
03/18/26	11	96413	—	1	$210.00	A
03/18/26	11	96415	—	1	$105.00	A

Boxes 25–33 · provider

25 Tax ID 58‑3390142 · 26 PCN2214 · 28 Total charge $5,155.00 · 29 Paid $0.00
31 S. Okonjo, MD · 32 Piedmont Digestive Health, 2210 Larkspur Commons Dr, Suite 300, Atlanta GA 30342 · 33a NPI 1447290183.

What Merid took from it

Box 23 carries the authorization number, so the claim told the plan at submission that this infusion had already been approved. JZ on the drug line is the Medicare attestation that no drug was discarded — 400 mg is exactly four 100 mg vials — carried on commercial lines as most practices do, and it removes wastage as a reason to question the units.

Cobalt Bay Health Plan provider remittanceRemittance

EFT 226041882702 Apr 2026ICN 2604188270

UNITEDHEALTHCARE PROVIDER REMITTANCE DATA        REPORT DATE: 04/02/2026
P.O. BOX 88120, ATLANTA, GA 30356               CHECK/EFT #: EFT 2260418827

PIEDMONT DIGESTIVE HEALTH, PC   NPI: 1447290183   TAX ID: 58-3390142
───────────────────────────────────────────────────────────────────────────
 SERV DATE  UNITS  PROC   MODS  BILLED   ALLOWED  GRP/RC-AMT     PROV PD
───────────────────────────────────────────────────────────────────────────
NAME ALVAREZ, MARTA R   MBR CBH884120773   ACNT PCN2214   ICN 2604188270
 0318 0318   40   J1745  JZ   4840.00     0.00  CO-50   4840.00     0.00
   REM: N130  step-therapy criteria not established for this drug
             and diagnosis.
 0318 0318    1   96413       210.00      0.00  CO-50    210.00     0.00
 0318 0318    1   96415       105.00      0.00  CO-50    105.00     0.00
   REM: administration denied with the drug.
 PT RESP 0.00   CLM STATUS 4   CLAIM TOTALS  5155.00  0.00  5155.00  0.00
───────────────────────────────────────────────────────────────────────────
GLOSSARY
 CO-50        Non-covered; not deemed a medical necessity by the payer.
 N130         Consult plan benefit documents for information about
              restrictions for this service.
 CLM STATUS 4 Denied.

What Merid took from it

A denial, not a write‑down. Status 4 is denied, the group is CO — the practice absorbs it and may not bill the patient under its participation agreement — and the reason is 50, medical necessity. All three lines fell together, so the encounter is at stake rather than a line of it.

Cobalt Bay Health Plan Pharmacy & Medical Policy ReviewDenial

2 Apr 2026Claim 2604188270Level 1 window: 180 days

P.O. Box 88120, Atlanta GA 30356 · 2 April 2026

Member CBH884120773 · Claim 2604188270 · NPI 1447290183

Dear Provider,

We have reviewed the claim referenced above for infliximab (J1745) administered on 18 March 2026. Coverage has been denied in full.

Reason CO‑50 — step‑therapy criteria are not established for this drug and diagnosis. Our review did not identify documented failure of both a corticosteroid and an immunomodulator, as required by the plan’s step‑therapy policy for tumor necrosis factor inhibitors.

A written appeal may be submitted within one hundred and eighty (180) days of this notice with supporting clinical documentation. Where documentation of prior therapy exists, include the agent, the dose, the duration and the reason for discontinuation.

Pharmacy & Medical Policy Review, Cobalt Bay Health Plan

What Merid took from it

The denial rests on a factual claim about the record — that failure of both agents is not documented — and the note documenting both was written nine weeks before the infusion. Nothing about the submission is wrong, so this is an appeal and not a corrected claim. The letter also names what it wants: agent, dose, duration, reason for discontinuation. The appeal answers in those four terms, in that order.

Determination letter — approvedAuthorization

Auth 0318-CBH-77421Issued 2 Mar 2026Valid 5 Mar – 3 Jun 2026

Cobalt Bay Health Plan Clinical Pharmacy Review · 2 March 2026

Field	Value
Member	Alvarez, Marta R · CBH884120773
Requested by	S. Okonjo, MD · NPI 1447290183
Drug	Infliximab (J1745), up to 400 mg per infusion
Regimen	Induction, weeks 0 / 2 / 6, then maintenance review
Place of service	11 — office infusion suite
Determination	Approved

This determination reflects a review of the submitted clinical documentation against the plan’s applicable coverage criteria, including step‑therapy requirements for tumor necrosis factor inhibitors.

Authorization is not a guarantee of payment. Payment remains subject to member eligibility on the date of service, benefit limits, and correct coding.

Clinical Pharmacy Review, Cobalt Bay Health Plan

What Merid took from it

This is the document the packet turns on, and the argument has to be made carefully. The plan is right that an authorization is not a guarantee of payment — eligibility, benefit limits and coding all survive it. Step therapy is not on that list. The plan reviewed these criteria against this record on 2 March and found them met; nothing in the record changed between 2 March and 18 March. So the appeal argues inconsistency, never entitlement.

Office visit · 14 Jan 2026Clinical

Alvarez, Marta RMRN 7742118S. Okonjo, MD

Assessment

Moderate‑to‑severe ileocolonic Crohn’s disease, steroid‑dependent. Harvey‑Bradshaw Index 11 today, up from 9 in November. Weight 80 kg.

Corticosteroid course

Prednisone 40 mg begun 3 June 2025; every attempt to taper below 20 mg has been followed by symptom return within two weeks. Three taper attempts documented (July, September, November). Cushingoid features and a 6 kg weight gain noted.

Immunomodulator trial

Azathioprine 200 mg daily from 1 August 2025 through 20 November 2025 — sixteen weeks at a therapeutic dose, with thiopurine metabolites in range (6‑TGN 284 pmol). No clinical or biochemical response. Discontinued for non‑response, not intolerance.

Plan

Failed conventional therapy. Initiate infliximab 5 mg/kg induction (weeks 0, 2, 6) in the infusion suite — 400 mg at 80 kg. TB and hepatitis screening negative 8 Jan.

What Merid took from it

Both prerequisites the policy asks for are here with dates and with objective markers. The corticosteroid course shows dependence rather than a simple trial; the azathioprine course shows a sixteen‑week therapeutic trial that failed, with metabolite levels proving the dose was adequate and the discontinuation recorded as non‑response rather than intolerance. That distinction is what the policy turns on, and it is why the quotes go in verbatim.

Cedar Ridge Clinical Laboratory · CLIA 11D0047792Labs

Alvarez, Marta RThree drawsOrdered by S. Okonjo, MD

Disease activity, serial

Analyte	1 Aug	20 Nov	12 Jan	Reference	Flag
Fecal calprotectin	842	910	1,040	< 50 µg/g	H
CRP	18	22	26	< 5 mg/L	H
Hemoglobin	11.9	11.4	11.1	12.0 – 16.0 g/dL	L
Albumin	3.6	3.4	3.2	3.5 – 5.0 g/dL	L

Thiopurine metabolites · 14 Nov 2025

Analyte	Value	Reference	Flag
6‑TGN	284	235 – 450 pmol/8×10⁸ RBC	Therapeutic
6‑MMP	1,120	< 5,700 pmol/8×10⁸ RBC	Normal

Pre-biologic screening · 8 Jan 2026

QuantiFERON‑TB Gold Plus: negative. HBsAg, anti‑HBc, anti‑HCV: negative.

What Merid took from it

The metabolite panel is the quiet load‑bearing document. A step‑therapy reviewer can dismiss a failed immunomodulator as an under‑dosed one; 6‑TGN at 284 pmol/8×10⁸ RBC, inside the therapeutic window closes that door with a number rather than an assertion. The serial markers rising across all three draws answer the other reading — that the disease was controlled and the escalation discretionary.

Infusion suite · 18 Mar 2026MAR

400 mg administered4 × 100 mg vials0 mg discarded

Time	Entry	Detail
09:04	Pre‑infusion observations	BP 118/74, HR 78, T 36.8 °C
09:12	Infliximab 400 mg in 250 mL NS	Infusion started, 10 mL/hr
09:42	Rate escalation per protocol	No reaction
11:14	Infusion complete	Total run time 2 hr 02 min
12:15	Post‑infusion observation ended	Discharged, no reaction

Drug accountability

Four 100 mg single‑dose vials reconstituted. Lot 4K21B, exp 09/2027. Dose administered 400 mg; quantity discarded 0 mg.

What Merid took from it

This record is what makes the two administration lines provable rather than asserted. A run time of 2 hr 02 min supports 96413 for the first hour and one unit of 96415 for the second, which is the pair billed — and zero discard is what puts JZ on the drug line instead of JW. Neither point is in dispute today, so the record is held on file and not sent: only what the letter cites goes into the packet, which is the minimum‑necessary rule applied to a chart.

Plan coverage criteria — TNF inhibitors, inflammatory bowel diseasePolicy

Version in force 18 Mar 2026Retrieved at date of serviceExhibit D

Criterion 3 — prior therapy. The member has had an inadequate response to, or intolerance of, both of the following, documented with agent, dose, duration and outcome:

(a) a corticosteroid, or documented corticosteroid dependence; and
(b) an immunomodulator (azathioprine, 6‑mercaptopurine or methotrexate) at a therapeutic dose for at least twelve consecutive weeks, unless contraindicated.

Criterion 4 — dosing. Induction at 5 mg/kg at weeks 0, 2 and 6 is consistent with these criteria.

What Merid took from it

The policy is pulled at the version that governed 18 March 2026, not the version on the site today — a criteria set that changed in between is a different document and a payer will say so. Criterion 3 asks for four things per agent, and the note supplies all four for both. Criterion 3(b) asks for twelve weeks; the record shows sixteen. Criterion 3(a) accepts dependence in the alternative, which is exactly what three failed tapers are.

Physician participation agreement — Exhibit B, drug reimbursementContract

Rate supplied by the practiceAtlanta commercial fee scheduleNot an exhibit

§4.2 Drugs administered in the office. Products billed under a HCPCS J code are reimbursed at the Medicare Part B ASP payment limit in effect when the claim is adjudicated, plus fifteen percent, less applicable member cost share.

Line	Basis	Factor	Allowed
J1745, 40 units	$31.041 / 10 mg	× 1.15	$1,427.89
96413, 1 unit	fee schedule	—	$181.44
96415, 1 unit	fee schedule	—	$39.71
Contracted allowed			$1,649.04

What Merid took from it

The billed amount is never the number. Charges were $5,155.00; the contract says the claim is worth $1,649.04, and that is the figure the letter asks for and the figure the case is measured against. Computed in code from the rate your practice supplied — no model is in this path.

Level 1 appeal — medical necessityLetter

Drafted 6 Apr 2026Due 29 Sep 2026Cites 6 exhibits

Piedmont Digestive Health, PC · 2210 Larkspur Commons Dr, Suite 300, Atlanta GA 30342
NPI 1447290183 · Tax ID 58‑3390142

6 April 2026 · Cobalt Bay Health Plan Appeals, P.O. Box 88121, Atlanta GA 30356
Re: Claim 2604188270 · Member CBH884120773 · DOS 18 March 2026

This is a first‑level appeal of the denial dated 2 April 2026. The denial states that step‑therapy criteria are not established. The record establishes them, and the plan has already found so once.

1. The plan approved these criteria against this record

Authorization 0318‑CBH‑77421, issued 2 March 2026, records a review of the submitted documentation against the plan’s applicable coverage criteria, including step‑therapy requirements for tumor necrosis factor inhibitors. ^[Ex. A] The authorization number was reported in Box 23. ^[Ex. B] We accept that authorization is not a guarantee of payment; eligibility, benefit limits and coding survive it. Step therapy is not among them, and no fact in the record changed between 2 and 18 March.

2. Criterion 3(a) — corticosteroid dependence

The note of 14 January 2026 records: Prednisone 40 mg begun 3 June 2025; every attempt to taper below 20 mg has been followed by symptom return within two weeks. ^[Ex. C] Three taper attempts are documented. Criterion 3(a) is met in the alternative it provides for. ^[Ex. D]

3. Criterion 3(b) — immunomodulator at therapeutic dose

Azathioprine 200 mg daily from 1 August 2025 through 20 November 2025 — sixteen weeks at a therapeutic dose… No clinical or biochemical response. ^[Ex. C] The policy asks for twelve weeks; the record shows sixteen. Adequacy of dose is not asserted but measured: 6‑TGN 284 pmol, within the therapeutic window. ^[Ex. E] Discontinuation is recorded as non‑response rather than intolerance, which is the distinction the criterion draws.

Relief requested

Reprocess claim 2604188270 and pay the contracted allowed amount of $1,649.04 (J1745 $1,427.89; 96413 $181.44; 96415 $39.71), the contracted allowed amount under the participation agreement.

S. Okonjo, MD

What Merid took from it

Three arguments, each ending in a quotation with an exhibit behind it, ordered so the cheapest one to verify comes first. Every sentence of fact resolves to a row of evidence, and the money is the contracted figure rather than the charge. No argument rests on the member’s appeal rights: this is the practice’s own post‑service dispute under its contract, so it needs no patient authorisation, and the letter says nothing it would need one to say.

The payer’s own form — checked, and correctly not usedChannel

Cobalt Bay Health PlanPost‑service clinical appealNo form attached

What the payer publishes	What it is for
Claim reconsideration form Form CBH‑R1, rev. 03/2026	Reimbursement disagreements — filing time, corrected claims, COB, a rate applied wrongly. Its own notes say: “Do not use this form for formal appeals or disputes.”
Provider Portal, or the API	Where this plan asks network professionals to send a post‑service appeal. The letter and the indexed exhibits attach here — through the API where the plan exposes one, otherwise uploaded by your approver.
Mail, to the appeals address	The fallback when electronic submission is not possible. Address from the payer’s verified channel row, cross‑checked against the determination letter.

Form row for this payer and this level: none. The row exists so the question is not asked again on the next case.

What Merid took from it

A payer publishing a form does not mean the form belongs on this packet, and attaching the wrong one is how a clinical appeal gets routed to the reconsideration queue and closed as a duplicate. Where a payer does want a form, its fields are filled from the case rather than typed — and any field the case cannot answer is left blank and named in the manifest, so nobody signs a form with a guess on it.

What is in the packet, and what each page is forManifest

5 exhibits · 11 pagesEvery citation resolvedDigest per document

Ex.	Document	Kind	Pages
A	Prior authorization	Authorization	2
B	CMS-1500 as submitted	From the claim and the remittance	1
C	Progress note, 14 Jan 2026	Excerpt from the medical record	3
D	Step-therapy policy, version in force	Excerpt from the payer’s coverage policy	3
E	Laboratory report	Excerpt from the medical record	2
—	Infusion record	Held on file, not sent	—

Packet sections: cover page · the letter · exhibits · the remittance line. form_key: none, so no form page and no unfilled fields to report.

Exhibits are lettered in the order the letter first cites them, so a reader meets Exhibit A before Exhibit B. Each carries a digest, and the manifest is stored without the packet so the record of what was sent survives the file.

What Merid took from it

The cite‑check runs before a human sees any of this: every factual sentence in the letter is re‑resolved against its evidence row, and a sentence that cannot quote its source stops the document rather than shipping with a footnote. Five exhibits, five resolved. Only then does it reach the queue for approval.

1 of 12 · CMS-1500 Claim

Fictitious case for demonstration. The patient, the practice and the claim are invented. The payer, its coverage policy and its forms are invented too. The HCPCS codes and the published Medicare drug payment limit the contract prices against are real.

Merid AI Example Workflow

Boxes 1–13 · patient and insured

Boxes 21–23 · diagnosis and authorization

Box 24 · service lines

Boxes 25–33 · provider

Empower your billing team