CLM-2026-016762
Meadow Imaging Center, Radiology. Service 2026-08-15 at outpatient hospital (POS 22). Received 2026-09-16.
Member
Resolved through the identity graph
- Member
- Drew Carroll
- Member ID
- UHC-88757-58
- Date of birth
- 1942-04-21
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-427212
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group NULL
- Coverage period
- 2024-07-01 to present
- Deductible
- $149.13 of $2,500.006%
- Out-of-pocket maximum
- $781.03 of $10,000.008%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 10 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
- PA2025861683 / 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 | $221.00 | $121.55 | $121.55 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $2,199.00 | $1,209.45 | $1,209.45 | $0.00 | Paid |
| Totals | $2,420.00 | $1,331.00 | $1,331.00 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-691155
- 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-041225 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-15: N/A (PPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025861683 on file for 74177. | |
| 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 Center2026-08-15 17:21
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025861683_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-08-15 to 2026-11-13.
- Itemized billitemized_PA-691155.pdf8 pages
Itemised statement totalling $2420.00 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-2026-019118 | 2026-09-25 | Canyon Cardiovascular Associates | $1,294.00 | 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.