CLM-2026-007765
Meadow Regional Medical Center, Emergency Medicine. Service 2026-03-30 at emergency room (POS 23). Received 2026-05-05.
Member
Resolved through the identity graph
- Member
- Jonathan Maldonado
- Member ID
- UHC-46045-09
- Date of birth
- 2002-06-14
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-407791
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0956
- Coverage period
- 2022-07-01 to 2026-08-19
- Deductible
- $524.77 of $2,500.0021%
- Out-of-pocket maximum
- $273.04 of $10,000.003%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1905050427
- Network
- In network
- Rendering NPI
- 1905050427
- Location
- Dallas, TX · TIN 71-2312931
- 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 | $90.20 | $0.00 | Paid |
| Totals | $164.00 | $90.20 | $90.20 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R55 Syncope and collapse
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-881879
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008097 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-30: SELECT-EPO (EPO), effective 2022-07-01, terms 2026-08-19. | |
| Timely filing | Pass | Received 36 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 Regional Medical Center (1905050427). | |
| 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 Regional Medical Center2026-03-30 16:56
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-881879.pdf2 pages
Itemised statement totalling $164.00 across 1 line.
- Er reported_report_PA-881879.pdf2 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025636 | 2025-12-16 | Northgate Counseling Center | $213.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.