CLM-2026-028305
Meadow Imaging Center, Radiology. Service 2026-09-21 at outpatient hospital (POS 22). Received 2026-09-30.
Member
Resolved through the identity graph
- Member
- Helen Patel
- Member ID
- UHC-69833-28
- Date of birth
- 1995-03-27
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-425210
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5659
- Coverage period
- 2023-07-01 to 2026-06-22
- Deductible
- $947.01 of $1,500.0063%
- Out-of-pocket maximum
- $1,374.19 of $3,000.0046%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 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
- PA2025500166 / 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 | $1,483.00 | $815.65 | — | — | DeniedCO27 |
| Totals | $1,483.00 | $815.65 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. R51.9 Headache, unspecified
- Patient account
- PA-473430
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004263 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-21 is after coverage terminated on 2026-06-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025500166 on file for 74177. | |
| 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 Center2026-09-21 10:19
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-30 05:03
Attachments
Documents received with the claim
- Prior auth letterPA2025500166_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-09-21 to 2026-12-20.
- Itemized billitemized_PA-473430.pdf4 pages
Itemised statement totalling $1483.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-21 is after coverage terminated on 2026-06-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012348 | 2026-02-02 | Meadow Regional Medical Center | $827.00 | Approved |
| CLM-2026-018017 | 2025-12-14 | Desert Clinical Laboratories | $82.00 | 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
Service after coverage termination.