CLM-2026-007692
Meadow Diagnostic Imaging, Radiology. Service 2026-08-14 at outpatient hospital (POS 22). Received 2026-08-22.
Member
Resolved through the identity graph
- Member
- Isabella Herrera
- Member ID
- UHC-23502-35
- Date of birth
- 1994-01-06
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400583
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group UNKNOWN
- Coverage period
- 2024-07-01 to present
- Deductible
- $1,101.83 of $1,500.0073%
- Out-of-pocket maximum
- $223.32 of $4,500.005%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3980491351
- Network
- Out of network
- Rendering NPI
- 3980491351
- Location
- Mesa, AZ · TIN 42-4436068
- Authorisation / referral
- PA2026066916 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,011.00 | $904.95 | — | — | DeniedCO204 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $125.00 | $56.25 | — | — | DeniedCO204 |
| Totals | $2,136.00 | $961.20 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-425607
- 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-035193 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-14: SELECT-EPO (EPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026066916 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 3980491351 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| Medical necessity | Review | CO50 | 70553 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 Diagnostic Imaging2026-08-14 09:23
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
- SystemSystem: Claims system2026-08-22 04:36
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-22 12:57
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026066916_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-14 to 2026-11-12.
- Itemized billitemized_PA-425607.pdf3 pages
Itemised statement totalling $2136.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 3980491351 is out of network and the EPO plan has no out-of-network benefit. Medical necessity: 70553 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
No out-of-network benefit on this plan.