CLM-2026-029395
Meadow Imaging Center, Radiology. Service 2026-05-23 at outpatient hospital (POS 22). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Wei Castillo
- Member ID
- UHC-42128-21
- Date of birth
- 1960-11-18
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-414350
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2641
- Coverage period
- 2025-10-01 to 2026-03-18
- Deductible
- $698.66 of $1,000.0070%
- Out-of-pocket maximum
- $724.98 of $2,000.0036%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 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 / REF826520
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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $317.00 | $174.35 | — | — | DeniedCO27 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1,2 | $222.00 | $122.10 | — | — | DeniedCO27 |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1,2 | $551.00 | $303.05 | — | — | DeniedCO27 |
| Totals | $1,090.00 | $599.50 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R51.9 Headache, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-854840
- 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-007055 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-23 is after coverage terminated on 2026-03-18. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-05-23 12:38
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-07 03:06
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-07 13:13
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-854840.pdf2 pages
Itemised statement totalling $1090.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-23 is after coverage terminated on 2026-03-18.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010461 | 2026-03-08 | Lakeside Medical Group | $393.00 | Denied |
| CLM-2026-026670 | 2025-12-10 | Canyon Diagnostic Imaging | $1,518.00 | Denied |
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.