CLM-2026-027366
Meadow Medical Group, Internal Medicine. Service 2026-01-04 at outpatient hospital (POS 22). Received 2026-01-22.
Member
Resolved through the identity graph
- Member
- Anthony Fox
- Member ID
- UHC-66246-41
- Date of birth
- 1976-04-21
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-426811
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6907
- Coverage period
- 2025-03-01 to present
- Deductible
- $2,969.48 of $3,500.0085%
- Out-of-pocket maximum
- $2,547.54 of $7,000.0036%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3950077545
- Network
- In network
- Rendering NPI
- 8626626559
- Location
- Denver, CO · TIN 15-9022901
- Authorisation / referral
- PA2025920630 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,248.00 | $1,236.40 | — | — | Review |
| Totals | $2,248.00 | $1,236.40 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-624263
- 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-006734 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-04: CHOICE-PLUS-PPO (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025920630 on file for 70553. | |
| Provider network | Pass | In-network provider Meadow Medical Group (3950077545). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Medical Group2026-01-04 09:44
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-22 03:50
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2025920630_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-04 to 2026-04-04.
- Itemized billitemized_PA-624263.pdf3 pages
Itemised statement totalling $2248.00 across 1 line.
- Medical recordrecords_PA-624263.pdf20 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Routine diagnosis does not support advanced imaging.