CLM-2026-015396
Meadow Diagnostic Imaging, Radiology. Service 2026-04-07 at outpatient hospital (POS 22). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Deborah Williams
- Member ID
- UHC-53086-07
- Date of birth
- 1967-12-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-400381
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0473
- Coverage period
- 2021-12-01 to present
- Deductible
- $680.68 of $2,500.0027%
- Out-of-pocket maximum
- $1,937.97 of $5,000.0039%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 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
- PA2026361754 / 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 | $358.00 | $161.10 | $161.10 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $237.00 | $106.65 | $106.65 | $0.00 | Paid |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,616.00 | $727.20 | $727.20 | $0.00 | Paid |
| Totals | $2,211.00 | $994.95 | $994.95 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-983101
- 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-007874 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-07: OPTIONS-PPO (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026361754 on file for 74177. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Imaging2026-04-07 10:12
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026361754_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-04-07 to 2026-07-06.
- Itemized billitemized_PA-983101.pdf3 pages
Itemised statement totalling $2211.00 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.