CLM-2026-009386
Meadow Regional Medical Center, Emergency Medicine. Service 2026-04-22 at emergency room (POS 23). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Alexis Diaz
- Member ID
- none on golden record
- Date of birth
- 1981-05-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422787
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Eligibility
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 | $224.00 | $123.20 | — | — | DeniedCO29 |
| Totals | $224.00 | $123.20 | — | — | ||||||
- 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. R55 Syncope and collapse
- Patient account
- PA-354899
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-042592 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Fail | CO29 | Received 126 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Center2026-04-22 15:00
Established patient presents with sprain of unspecified ligament of right ankle, initial encounter; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-26 04:37
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-26 17:24
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-354899.pdf7 pages
Itemised statement totalling $224.00 across 1 line.
- Er reported_report_PA-354899.pdf6 pages
Emergency department record: triage acuity 3, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim. Timely filing: Received 126 days after the last date of service (limit 90).
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
Received after the timely-filing limit.