CLM-2026-015716
Meadow Imaging Center, Radiology. Service 2026-06-26 at outpatient hospital (POS 22). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Laura Little
- Member ID
- UHC-72641-27
- Date of birth
- 2001-07-05
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-420749
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4787
- Coverage period
- 2023-12-01 to present
- Deductible
- $413.40 of $1,000.0041%
- Out-of-pocket maximum
- $287.48 of $3,000.0010%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 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
- PA2026997040 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,349.00 | $1,291.95 | $657.14 | $634.81 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $131.00 | $72.05 | $7.21 | $64.84 | Paid |
| Totals | $2,480.00 | $1,364.00 | $664.35 | $699.65 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-437963
- 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-033248 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-26: CHOICE-PLUS-PPO (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026997040 on file for 70553. | |
| 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 Center2026-06-26 09:17
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026997040_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-26 to 2026-09-24.
- Itemized billitemized_PA-437963.pdf9 pages
Itemised statement totalling $2480.00 across 2 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-2026-015717 | 2026-06-26 | Meadow Imaging Center | $2,480.00 | Denied |
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.