CLM-2026-009559
Meadow Imaging Center, Radiology. Service 2026-01-22 at outpatient hospital (POS 22). Received 2026-01-31.
Member
Resolved through the identity graph
- Member
- Donna Adams
- Member ID
- UHC-77847-88
- Date of birth
- 1983-01-09
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-429590
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7183
- Coverage period
- 2022-02-01 to 2026-08-08
- Deductible
- $776.31 of $1,000.0078%
- Out-of-pocket maximum
- $999.31 of $2,000.0050%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $394.00 | $216.70 | $216.70 | $0.00 | Paid |
| Totals | $394.00 | $216.70 | $216.70 | $0.00 | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R51.9 Headache, unspecified
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-595642
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009195 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-22: SELECT-EPO (EPO), effective 2022-02-01, terms 2026-08-08. | |
| Timely filing | Pass | Received 9 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Imaging Center2026-01-22 15:27
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-595642.pdf2 pages
Itemised statement totalling $394.00 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 12:44Clean claim.
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.