CLM-2026-022249
Meadow Imaging Center, Radiology. Service 2025-12-14 at outpatient hospital (POS 22). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Judith Mendez
- Member ID
- UHC-36385-95
- Date of birth
- 1988-03-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-431743
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3513
- Coverage period
- 2025-02-01 to present
- Deductible
- $665.40 of $1,500.0044%
- Out-of-pocket maximum
- $209.14 of $3,000.007%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 9 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
- PA2025751102 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,338.00 | $735.90 | $735.90 | $0.00 | Paid |
| Totals | $1,338.00 | $735.90 | $735.90 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-752560
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005606 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-14: OPTIONS-PPO (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025751102 on file for 74177. | |
| Provider network | Pass | In-network provider Meadow Imaging Center (1741122406). | |
| 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 Center2025-12-14 13:33
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025751102_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-12-14 to 2026-03-14.
- Itemized billitemized_PA-752560.pdf4 pages
Itemised statement totalling $1338.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030352 | 2026-01-14 | Riverside Cardiovascular Associates | $332.00 | Approved |
| CLM-2026-022250 | 2025-12-14 | Meadow Imaging Center | $1,338.00 | Denied |
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.