CLM-2026-008573
Meadow Diagnostic Imaging, Radiology. Service 2026-07-24 at outpatient hospital (POS 22). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- Benjamin Yang
- Member ID
- UHC-43975-07
- Date of birth
- 1944-10-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416672
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7756
- Coverage period
- 2021-03-01 to present
- Deductible
- $608.30 of $1,000.0061%
- Out-of-pocket maximum
- $449.13 of $2,000.0022%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 11 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
- PA2026541716 / 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 | $1,990.00 | $895.50 | $492.46 | $403.04 | Paid |
| Totals | $1,990.00 | $895.50 | $492.46 | $403.04 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-469820
- 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-036421 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-24: MEDICARE-ADV-B (MA), effective 2021-03-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026541716 on file for 70553. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Diagnostic Imaging2026-07-24 10:39
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026541716_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-24 to 2026-10-22.
- Itemized billitemized_PA-469820.pdf7 pages
Itemised statement totalling $1990.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.