CLM-2026-019664
Meadow Imaging Center, Radiology. Service 2026-06-27 at outpatient hospital (POS 22). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Denise Dunn
- Member ID
- UHC-66614-26
- Date of birth
- 1954-05-11
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-405529
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4923
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,885.30 of $3,500.0054%
- Out-of-pocket maximum
- $4,468.11 of $14,000.0032%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 0 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
- PA2026844019 / 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 | $171.00 | $94.05 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $3,413.00 | $1,877.15 | — | — | Review |
| Totals | $3,584.00 | $1,971.20 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-745941
- 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-009332 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-06-27: CHOICE-PLUS-PPO (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026844019 on file for 70553. | |
| Provider network | Pass | In-network provider Meadow Imaging Center (4402940280). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Center2026-06-27 11:18
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026844019_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-06-27 to 2026-09-25.
- Itemized billitemized_PA-745941.pdf5 pages
Itemised statement totalling $3584.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005488 | 2026-06-18 | Mesa GI Associates | $2,458.00 | Approved |
| CLM-2026-020738 | 2026-03-30 | Canyon Reference Lab | $118.00 | Approved |
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.