CLM-2026-010145
Meadow Diagnostic Imaging, Radiology. Service 2026-04-21 at outpatient hospital (POS 22). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Kelly Harper
- Member ID
- UHC-75619-53
- Date of birth
- 2003-03-10
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-401749
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1606
- Coverage period
- 2024-03-01 to present
- Deductible
- $209.15 of $500.0042%
- Out-of-pocket maximum
- $539.26 of $2,000.0027%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 6 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
- 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 | $136.00 | $61.20 | — | — | DeniedCO204 |
| Totals | $136.00 | $61.20 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-359650
- 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-033589 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-21: SELECT-EPO (EPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 44 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 | 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 | 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 Imaging2026-04-21 12:09
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-06-04 05:59
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-359650.pdf3 pages
Itemised statement totalling $136.00 across 1 line.
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.
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.