CLM-2026-031287
Meadow Diagnostic Imaging, Radiology. Service 2026-01-12 at outpatient hospital (POS 22). Received 2026-02-11.
Member
Resolved through the identity graph
- Member
- Adam Griffin
- Member ID
- UHC-38974-87
- Date of birth
- 1984-03-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-423677
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3872
- Coverage period
- 2025-01-01 to present
- Deductible
- $3,123.69 of $3,500.0089%
- Out-of-pocket maximum
- $2,682.06 of $7,000.0038%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3980491351
- Network
- Out of network
- Rendering NPI
- 3980491351
- Location
- Mesa, AZ · TIN 42-4436068
- 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $315.00 | $141.75 | — | — | DeniedCO204 |
| Totals | $315.00 | $141.75 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-895440
- 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-008268 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-12: NAVIGATE-HMO (HMO), effective 2025-01-01. | |
| Timely filing | Pass | Received 30 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 | Fail | CO204 | Billing provider 3980491351 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Diagnostic Imaging2026-01-12 15:50
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-11 02:51
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-895440.pdf2 pages
Itemised statement totalling $315.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 3980491351 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000063 | 2025-12-24 | Pinecrest Behavioral Health | $3,409.00 | Needs review |
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
No out-of-network benefit on this plan.