CLM-2026-032019
Meadow Diagnostic Imaging, Radiology. Service 2026-08-09 at outpatient hospital (POS 22). Received 2026-09-15.
Member
Resolved through the identity graph
- Member
- Ralph Ruiz
- Member ID
- UHC-43941-81
- Date of birth
- 1954-06-03
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-416639
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0833
- Coverage period
- 2024-04-01 to present
- Deductible
- $684.99 of $1,500.0046%
- Out-of-pocket maximum
- $803.73 of $6,000.0013%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 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
- PA2025309961 / 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 | $407.00 | $183.15 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $188.00 | $84.60 | — | — | Review |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $2,214.00 | $996.30 | — | — | Review |
| Totals | $2,809.00 | $1,264.05 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-381861
- 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-017033 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-08-09: MEDICARE-ADV-B (MA), effective 2024-04-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025309961 on file for 70553. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Review | CO50 | 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 Diagnostic Imaging2026-08-09 14:36
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Prior auth letterPA2025309961_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-08-09 to 2026-11-07.
- Itemized billitemized_PA-381861.pdf2 pages
Itemised statement totalling $2809.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002382 | 2026-06-29 | Cornerstone Imaging Center | $2,519.00 | 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
Clean claim, priced at contract rate.