CLM-2026-018511
Meadow Imaging Center, Radiology. Service 2026-07-22 at outpatient hospital (POS 22). Received 2026-08-21.
Member
Resolved through the identity graph
- Member
- Anna Bowman
- Member ID
- UHC-89187-82
- Date of birth
- 2007-03-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428778
- Relationship
- Child, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0406
- Coverage period
- 2025-07-01 to 2026-01-08
- Deductible
- $512.24 of $1,500.0034%
- Out-of-pocket maximum
- $1,680.02 of $6,000.0028%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 0 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
- PA2026977887 / REF735969
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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,313.00 | $722.15 | — | — | DeniedCO27 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $229.00 | $125.95 | — | — | DeniedCO27 |
| 3 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1 | $123.00 | $67.65 | — | — | DeniedCO27 |
| Totals | $1,665.00 | $915.75 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-758973
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030140 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-22 is after coverage terminated on 2026-01-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026977887 on file for 74177. | |
| 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 Center2026-07-22 17:47
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-08-21 06:43
Attachments
Documents received with the claim
- Prior auth letterPA2026977887_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-07-22 to 2026-10-20.
- Itemized billitemized_PA-758973.pdf7 pages
Itemised statement totalling $1665.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-22 is after coverage terminated on 2026-01-08.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019974 | 2026-08-10 | Lakeside Endocrine Associates | $619.00 | Denied |
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
Service after coverage termination.