CLM-2026-025794
Meadow Imaging Center, Radiology. Service 2026-07-27 at outpatient hospital (POS 22). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Sarah Sanders
- Member ID
- UHC-10031-33
- Date of birth
- 1961-05-12
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-400221
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7280
- Coverage period
- 2023-06-01 to 2026-02-01
- Deductible
- $382.74 of $1,500.0026%
- Out-of-pocket maximum
- $1,926.97 of $4,500.0043%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 20 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
- PA2026369954 / 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $264.00 | $145.20 | — | — | DeniedCO27 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $197.00 | $108.35 | — | — | DeniedCO27 |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $3,075.00 | $1,691.25 | — | — | DeniedCO27 |
| Totals | $3,536.00 | $1,944.80 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-937633
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033082 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-27 is after coverage terminated on 2026-02-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026369954 on file for 70553. | |
| 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 Center2026-07-27 15:26
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-20 03:23
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-20 08:32
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026369954_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-07-27 to 2026-10-25.
- Itemized billitemized_PA-937633.pdf4 pages
Itemised statement totalling $3536.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-27 is after coverage terminated on 2026-02-01.
Other claims for this member
Same resolved identity
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
Service after coverage termination.