CLM-2026-017539
Meadow Imaging Center, Radiology. Service 2026-02-04 at outpatient hospital (POS 22). Received 2026-02-11.
Member
Resolved through the identity graph
- Member
- Bobby Moreno
- Member ID
- UHC-17565-73
- Date of birth
- 1969-02-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-403876
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9303
- Coverage period
- 2024-12-01 to present
- Deductible
- $181.81 of $1,000.0018%
- Out-of-pocket maximum
- $1,135.13 of $4,000.0028%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 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
- PA2025228379 / 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 | $301.00 | $165.55 | $165.55 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,010.00 | $1,655.50 | $953.50 | $702.00 | Paid |
| Totals | $3,311.00 | $1,821.05 | $1,119.05 | $702.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. R51.9 Headache, unspecified
- Patient account
- PA-200878
- 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-012225 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-04: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025228379 on file for 70553. | |
| 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 Center2026-02-04 15:36
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025228379_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-02-04 to 2026-05-05.
- Itemized billitemized_PA-200878.pdf2 pages
Itemised statement totalling $3311.00 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
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.