CLM-2026-027196
Meadow Diagnostic Imaging, Radiology. Service 2026-06-16 at outpatient hospital (POS 22). Received 2026-07-14.
Member
Resolved through the identity graph
- Member
- Karen Williamson
- Member ID
- UHC-19624-91
- Date of birth
- 1989-01-28
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-403728
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0204
- Coverage period
- 2022-03-01 to present
- Deductible
- $889.76 of $1,500.0059%
- Out-of-pocket maximum
- $1,414.94 of $3,000.0047%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3980491351
- Network
- Out of network
- Rendering NPI
- 3980491351
- Location
- Mesa, AZ · TIN 42-4436068
- Authorisation / referral
- PA2025953115 / REF838475
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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,440.00 | $1,548.00 | — | — | DeniedCO204 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,839.00 | $827.55 | — | — | DeniedCO204 |
| 3 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $380.00 | $171.00 | — | — | DeniedCO204 |
| Totals | $5,659.00 | $2,546.55 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-546360
- 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-005365 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-16: CORE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025953115 on file for 70553, 74177. | |
| Provider network | Fail | CO204 | Billing provider 3980491351 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Diagnostic Imaging2026-06-16 18:20
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-14 03:54
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2025953115_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-16 to 2026-09-14.
- Itemized billitemized_PA-546360.pdf4 pages
Itemised statement totalling $5659.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 3980491351 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.