CLM-2026-021955
Meadow Imaging Center, Radiology. Service 2026-08-31 at outpatient hospital (POS 22). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Doris Matthews
- Member ID
- UHC-22585-01
- Date of birth
- 1944-07-09
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-403827
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5917
- Coverage period
- 2021-12-01 to present
- Deductible
- $216.32 of $500.0043%
- Out-of-pocket maximum
- $22.39 of $1,000.002%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 9 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 / REF274787
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 | $228.00 | $125.40 | $125.40 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $575.00 | $316.25 | $205.67 | $110.58 | Paid |
| Totals | $803.00 | $441.65 | $331.07 | $110.58 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-556661
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033097 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-31: NAVIGATE-HMO (HMO), effective 2021-12-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| 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 Center2026-08-31 16:15
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-556661.pdf9 pages
Itemised statement totalling $803.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.