CLM-2026-021080
Meadow Imaging Center, Radiology. Service 2026-04-19 at outpatient hospital (POS 22). Received 2026-05-26.
Member
Resolved through the identity graph
- Member
- Kayla Henry
- Member ID
- UHC-88085-99
- Date of birth
- 1969-11-11
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-406511
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6746
- Coverage period
- 2024-06-01 to present
- Deductible
- $467.52 of $1,500.0031%
- Out-of-pocket maximum
- $1,627.28 of $4,500.0036%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 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
- none / 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 | $197.00 | $108.35 | — | — | DeniedCO18 |
| Totals | $197.00 | $108.35 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-887955
- 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-006895 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-19: MEDICARE-ADV-A (MA), effective 2024-06-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-021079: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-04-19 15:51
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-05-26 04:45
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-887955.pdf6 pages
Itemised statement totalling $197.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-021079: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010995 | 2026-08-25 | Mesa Dermatology Clinic | $512.00 | Approved |
| CLM-2026-012285 | 2026-05-25 | Northgate Clinical Laboratories | $105.00 | Approved |
| CLM-2026-021079 | 2026-04-19 | Meadow Imaging Center | $197.00 | Approved |
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
Exact duplicate of an earlier submission.