CLM-2026-014307
Meadow Imaging Center, Radiology. Service 2026-03-27 at outpatient hospital (POS 22). Received 2026-04-17.
Member
Resolved through the identity graph
- Member
- Timothy Moreno
- Member ID
- UHC-31931-34
- Date of birth
- 2005-05-02
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-420135
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4500
- Coverage period
- 2023-01-01 to 2026-01-23
- Deductible
- $346.81 of $500.0069%
- Out-of-pocket maximum
- $65.36 of $2,000.003%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $412.00 | $226.60 | — | — | DeniedCO27 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $158.00 | $86.90 | — | — | DeniedCO27 |
| 3 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $378.00 | $207.90 | — | — | DeniedCO27 |
| Totals | $948.00 | $521.40 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-247737
- 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-026331 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-27 is after coverage terminated on 2026-01-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 Center2026-03-27 15:53
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-17 03:27
Attachments
Documents received with the claim
- Itemized billitemized_PA-247737.pdf5 pages
Itemised statement totalling $948.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-27 is after coverage terminated on 2026-01-23.
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
Service after coverage termination.