CLM-2026-016330
Meadow Diagnostic Imaging, Radiology. Service 2026-08-18 at outpatient hospital (POS 22). Received 2026-09-11.
Member
Resolved through the identity graph
- Member
- Denise Adams
- Member ID
- none on golden record
- Date of birth
- 1991-08-09
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-425565
- Relationship
- Self
Coverage and accumulators
Eligibility
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
- 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $1,975.00 | $888.75 | — | — | DeniedCO197 |
| Totals | $1,975.00 | $888.75 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-750731
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 4 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003761; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Imaging2026-08-18 13:13
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-11 05:42
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-750731.pdf6 pages
Itemised statement totalling $1975.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-003761; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Prior authorisation: 70553 require precertification; no authorisation number on the claim. Provider 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
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.