CLM-2026-028586
Meadow Imaging Center, Radiology. Service 2026-09-23 at outpatient hospital (POS 22). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Larry Barnes
- Member ID
- UHC-76599-05
- Date of birth
- 1958-04-09
- Identity
- Verified7 records, confidence 0.96
- Claim record
- CLMCLM-406038
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3520
- Coverage period
- 2024-08-01 to present
- Deductible
- $190.80 of $1,500.0013%
- Out-of-pocket maximum
- $1,402.43 of $4,500.0031%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 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
- PA2025545943 / 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 | $2,094.00 | $1,151.70 | — | — | Review |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $421.00 | $231.55 | — | — | Review |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $136.00 | $74.80 | — | — | Review |
| Totals | $2,651.00 | $1,458.05 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-690920
- 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-024690 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-23: MEDICARE-ADV-A (MA), effective 2024-08-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025545943 on file for 70553. | |
| Provider network | Pass | In-network provider Meadow Imaging Center (4402940280). | |
| 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 Imaging Center2026-09-23 11:38
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-10-05 05:36
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-05 08:45
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025545943_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-23 to 2026-12-22.
- Itemized billitemized_PA-690920.pdf7 pages
Itemised statement totalling $2651.00 across 3 lines.
- Medical recordrecords_PA-690920.pdf20 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031641 | 2026-08-20 | Sunrise Internal Medicine Associates | $342.00 | Approved |
| CLM-2026-022942 | 2026-04-06 | Riverside GI Associates | $2,184.00 | Approved |
| CLM-2026-004825 | 2026-05-09 | Mesa Medical Group | $259.00 | Approved |
| CLM-2026-032633 | 2026-04-07 | Lakeside Regional Medical Center | $255.00 | Approved |
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
Notes document medical necessity.