CLM-2026-033035
Meadow Imaging Center, Radiology. Service 2026-03-21 at outpatient hospital (POS 22). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Teresa Gonzales
- Member ID
- UHC-82828-61
- Date of birth
- 1961-04-23
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-410683
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6303
- Coverage period
- 2024-09-01 to present
- Deductible
- $48.82 of $3,500.001%
- Out-of-pocket maximum
- $2,069.68 of $7,000.0030%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 12 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
- PA2025915884 / 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 | $1,576.00 | $866.80 | $866.80 | $0.00 | Paid |
| Totals | $1,576.00 | $866.80 | $866.80 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-803371
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019692 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-03-21: MEDICARE-ADV-A (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025915884 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 Center2026-03-21 16:59
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025915884_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-03-21 to 2026-06-19.
- Itemized billitemized_PA-803371.pdf5 pages
Itemised statement totalling $1576.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019312 | 2026-02-10 | Mesa Orthopedic Specialists | $421.00 | Needs review |
| CLM-2026-019311 | 2026-02-10 | Mesa Orthopedic Specialists | $421.00 | Approved |
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.