CLM-2026-021751
Meadow Imaging Center, Radiology. Service 2026-07-29 at outpatient hospital (POS 22). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Mateo Coleman
- Member ID
- UHC-67652-54
- Date of birth
- 1985-03-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-432118
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2841
- Coverage period
- 2022-11-01 to present
- Deductible
- $75.07 of $1,000.008%
- Out-of-pocket maximum
- $884.03 of $2,000.0044%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 4 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
- PA2025565003 / 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 | $173.00 | $95.15 | — | — | Review |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1,2 | $2,211.00 | $1,216.05 | — | — | Review |
| 3 | 77067 rev 0403 | Screening mammography, bilateral | 25 | 1 | 2 | $298.00 | $163.90 | — | — | Review |
| Totals | $2,682.00 | $1,475.10 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R51.9 Headache, unspecified
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-360393
- 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-041611 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-29: MEDICARE-ADV-A (MA), effective 2022-11-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025565003 on file for 74177. | |
| Provider network | Pass | In-network provider Meadow Imaging Center (1741122406). | |
| Medical necessity | Review | CO50 | 74177 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 Center2026-07-29 16:54
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Prior auth letterPA2025565003_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-07-29 to 2026-10-27.
- Itemized billitemized_PA-360393.pdf7 pages
Itemised statement totalling $2682.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 74177 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-2026-022115 | 2026-09-07 | Evergreen Medical Group | $499.00 | 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.