CLM-2026-014348
Meadow Imaging Center, Radiology. Service 2026-04-28 at outpatient hospital (POS 22). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Madison Franklin
- Member ID
- UHC-89354-81
- Date of birth
- 1975-01-16
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-429678
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5925
- Coverage period
- 2021-09-01 to present
- Deductible
- $204.57 of $1,000.0020%
- Out-of-pocket maximum
- $78.46 of $2,000.004%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $131.00 | $72.05 | $72.05 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | 25 | 1 | 1 | $227.00 | $124.85 | $124.85 | $0.00 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1,2 | $623.00 | $342.65 | $342.65 | $0.00 | Paid |
| Totals | $981.00 | $539.55 | $539.55 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-940305
- 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-008281 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-28: SELECT-EPO (EPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 22 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 Center2026-04-28 15:51
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-940305.pdf3 pages
Itemised statement totalling $981.00 across 3 lines.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024955 | 2026-06-17 | Valley Internal Medicine Associates | $228.00 | Approved |
| CLM-2026-010754 | 2026-03-18 | Mesa GI Associates | $247.00 | Approved |
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.