CLM-2026-012909
Meadow Imaging Center, Radiology. Service 2026-07-06 at outpatient hospital (POS 22). Received 2026-07-18.
Member
Resolved through the identity graph
- Member
- Jacob Grant
- Member ID
- UHC-57440-22
- Date of birth
- 1969-10-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428777
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5693
- Coverage period
- 2023-04-01 to 2026-05-24
- Deductible
- $166.22 of $2,500.007%
- Out-of-pocket maximum
- $4,243.06 of $10,000.0042%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 1741122406
- Network
- In network
- Rendering NPI
- 1741122406
- Location
- Minneapolis, MN · TIN 23-3617085
- Authorisation / referral
- PA2025074274 / REF137088
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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,488.00 | $1,368.40 | — | — | DeniedCO27 |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $554.00 | $304.70 | — | — | DeniedCO27 |
| Totals | $3,042.00 | $1,673.10 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-260014
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013379 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-06 is after coverage terminated on 2026-05-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025074274 on file for 74177. | |
| Provider network | Pass | In-network provider Meadow Imaging Center (1741122406). | |
| 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 Center2026-07-06 12:28
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-18 01:20
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-18 13:35
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025074274_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-07-06 to 2026-10-04.
- Itemized billitemized_PA-260014.pdf4 pages
Itemised statement totalling $3042.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-06 is after coverage terminated on 2026-05-24.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010160 | 2026-04-30 | Pinecrest Medical Group | $50.00 | Needs review |
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
Service after coverage termination.