CLM-2026-001515
Meadow Imaging Center, Radiology. Service 2026-06-11 at outpatient hospital (POS 22). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Brrandon Peters
- Member ID
- UHC-02094-11
- Date of birth
- 1951-06-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-400024
- Relationship
- Child
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7824
- Coverage period
- 2024-10-01 to 2026-05-12
- Deductible
- $2,660.17 of $3,500.0076%
- Out-of-pocket maximum
- $2,283.00 of $7,000.0033%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 1741122406
- Network
- In network
- Rendering NPI
- 1741122406
- Location
- Minneapolis, MN · TIN 23-3617085
- Authorisation / referral
- PA2025826255 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $366.00 | $201.30 | — | — | DeniedCO27 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1,2 | $1,999.00 | $1,099.45 | — | — | DeniedCO27 |
| Totals | $2,365.00 | $1,300.75 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-868493
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-039307 (provisional, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-11 is after coverage terminated on 2026-05-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025826255 on file for 74177. | |
| Provider network | Pass | In-network provider Meadow Imaging Center (1741122406). | |
| Medical necessity | Review | CO50 | 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Imaging Center2026-06-11 10:37
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
- SystemSystem: Claims system2026-07-22 00:46
Attachments
Documents received with the claim
- Prior auth letterPA2025826255_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-06-11 to 2026-09-09.
- Itemized billitemized_PA-868493.pdf4 pages
Itemised statement totalling $2365.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-11 is after coverage terminated on 2026-05-12. Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
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.