CLM-2026-019355
Meadow Diagnostic Imaging, Radiology. Service 2026-06-04 at outpatient hospital (POS 22). Received 2026-07-18.
Member
Resolved through the identity graph
- Member
- Wei Andrews
- Member ID
- UHC-89962-52
- Date of birth
- 1953-01-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415485
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0302
- Coverage period
- 2024-01-01 to present
- Deductible
- $1,405.74 of $3,500.0040%
- Out-of-pocket maximum
- $2,638.47 of $7,000.0038%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
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
- PA2025317231 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $220.00 | $99.00 | — | — | PendedIDQ |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $2,509.00 | $1,129.05 | — | — | PendedIDQ |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $2,415.00 | $1,086.75 | — | — | PendedIDQ |
| Totals | $5,144.00 | $2,314.80 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-655608
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000462; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-04: UNKNOWN (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025317231 on file for 70553, 74177. | |
| 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 Imaging2026-06-04 18:47
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025317231_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-06-04 to 2026-09-02.
- Itemized billitemized_PA-655608.pdf6 pages
Itemised statement totalling $5144.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000462; payment withheld until the identity is confirmed. 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
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.