CLM-2026-032260
Meadow Imaging Center, Radiology. Service 2026-09-05 at outpatient hospital (POS 22). Received 2026-09-15.
Member
Resolved through the identity graph
- Member
- Brandon Marquez
- Member ID
- none on golden record
- Date of birth
- 1988-10-02
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406265
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-0627
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,650.39 of $2,500.0066%
- Out-of-pocket maximum
- $2,017.11 of $5,000.0040%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- 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
- PA2026292235 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $580.00 | $319.00 | $319.00 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,248.00 | $686.40 | $561.77 | $124.63 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $118.00 | $64.90 | $12.98 | $51.92 | Paid |
| Totals | $1,946.00 | $1,070.30 | $893.75 | $176.55 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-783004
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-044182 (provisional, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-09-05: MEDICARE-ADV-A (MA), effective 2023-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026292235 on file for 74177. | |
| 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 Center2026-09-05 16:32
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026292235_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-09-05 to 2026-12-04.
- Itemized billitemized_PA-783004.pdf8 pages
Itemised statement totalling $1946.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Eligibility: Active on 2026-09-05: MEDICARE-ADV-A (MA), effective 2023-01-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.