CLM-2026-003896
Meadow Imaging Center, Radiology. Service 2026-05-18 at outpatient hospital (POS 22). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Ann Hudson
- Member ID
- UHC-68157-21
- Date of birth
- 1947-09-06
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-419329
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8152
- Coverage period
- 2022-08-01 to present
- Deductible
- $59.22 of $500.0012%
- Out-of-pocket maximum
- $132.31 of $1,000.0013%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4402940280
- Network
- In network
- Rendering NPI
- 4402940280
- Location
- San Diego, CA · TIN 30-5345877
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $164.00 | $90.20 | — | — | Review |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $263.00 | $144.65 | — | — | Review |
| Totals | $427.00 | $234.85 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-372354
- 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-002370 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-18: CHOICE-PLUS-PPO (PPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 14 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 Imaging Center (4402940280). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for headache, unspecified. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Imaging Center2026-05-18 13:07
Patient seen for headache, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-01 00:00
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-01 17:24
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-372354.pdf7 pages
Itemised statement totalling $427.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for headache, unspecified. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028434 | 2026-04-18 | Canyon Diagnostic Imaging | $3,918.00 | Approved |
| CLM-2026-033470 | 2026-01-20 | Valley Family Practice | $502.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.