CLM-2026-031811
Meadow Imaging Center, Radiology. Service 2026-08-19 at outpatient hospital (POS 22). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Lucia Russell
- Member ID
- UHC-13987-43
- Date of birth
- 1969-01-23
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-414464
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1118
- Coverage period
- 2023-12-01 to 2026-04-10
- Deductible
- $892.19 of $3,500.0025%
- Out-of-pocket maximum
- $354.49 of $10,500.003%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 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
- PA2026657811 / 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 | $1,668.00 | $917.40 | — | — | DeniedCO27 |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,445.00 | $1,894.75 | — | — | DeniedCO27 |
| Totals | $5,113.00 | $2,812.15 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-590113
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016085 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-19 is after coverage terminated on 2026-04-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026657811 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Meadow Imaging Center (4402940280). | |
| Medical necessity | Review | CO50 | 74177, 70553 billed with routine diagnosis Z12.31; 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 Center2026-08-19 09:38
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
- SystemSystem: Claims system2026-09-14 05:50
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-14 09:14
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026657811_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-19 to 2026-11-17.
- Itemized billitemized_PA-590113.pdf5 pages
Itemised statement totalling $5113.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-19 is after coverage terminated on 2026-04-10. Medical necessity: 74177, 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
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
Service after coverage termination.