CLM-2026-027864
Meadow Imaging Center, Radiology. Service 2026-01-02 at outpatient hospital (POS 22). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Ema Capman
- Member ID
- UHC-69747-90
- Date of birth
- 1990-12-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424350
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5887
- Coverage period
- 2025-12-01 to present
- Deductible
- $419.46 of $1,000.0042%
- Out-of-pocket maximum
- $1,071.53 of $4,000.0027%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4402940280
- Network
- In network
- Rendering NPI
- 4402940280
- Location
- San Diego, CA · TIN 30-5345877
- 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,861.00 | $1,573.55 | — | — | DeniedCO197 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $236.00 | $129.80 | — | — | DeniedCO197 |
| Totals | $3,097.00 | $1,703.35 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- 3. M25.561 Pain in right knee
- Patient account
- PA-738536
- 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-003628 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-02: OPTIONS-PPO (PPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Meadow Imaging Center (4402940280). | |
| 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 Center2026-01-02 14:39
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-12 03:58
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-12 08:40
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-738536.pdf7 pages
Itemised statement totalling $3097.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 70553 require precertification; no authorisation number on the claim.
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
Precertification required and absent.