CLM-2026-026816
Meadow Imaging Center, Radiology. Service 2026-01-04 at outpatient hospital (POS 22). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Samantha Reid
- Member ID
- UHC-04297-64
- Date of birth
- 1944-10-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-422574
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2601
- Coverage period
- 2025-10-01 to present
- Deductible
- $43.57 of $3,500.001%
- Out-of-pocket maximum
- $1,241.66 of $7,000.0018%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 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
- 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,248.00 | $686.40 | — | — | DeniedCO197 |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,477.00 | $1,912.35 | — | — | DeniedCO197 |
| Totals | $4,725.00 | $2,598.75 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R51.9 Headache, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-276807
- 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-006491 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-04: OPTIONS-PPO (PPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177, 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2026-01-04 15:55
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-21 04:28
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-21 15:41
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-276807.pdf2 pages
Itemised statement totalling $4725.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 74177, 70553 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019980 | 2026-01-29 | Lakeside Clinical Laboratories | $35.00 | 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
Precertification required and absent.