CLM-2026-034294
Meadow GI Associates, Gastroenterology. Service 2025-12-09 at outpatient hospital (POS 22). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Kathy Baker
- Member ID
- UHC-30409-08
- Date of birth
- 1991-09-15
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-406763
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8143
- Coverage period
- 2023-01-01 to present
- Deductible
- $224.48 of $2,500.009%
- Out-of-pocket maximum
- $3,085.33 of $7,500.0041%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1813475971
- Network
- In network
- Rendering NPI
- 8434406566
- Location
- Austin, TX · TIN 38-1568789
- Authorisation / referral
- PA2026868060 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $1,856.00 | $1,020.80 | — | — | Review |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1,2 | $269.00 | $147.95 | — | — | Review |
| 3 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1,2 | $2,198.00 | $1,208.90 | — | — | Review |
| Totals | $4,323.00 | $2,377.65 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-473836
- 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-002655 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-09: MEDICARE-ADV-B (MA), effective 2023-01-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026868060 on file for 70553, 45378. | |
| Provider network | Pass | In-network provider Meadow GI Associates (1813475971). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; 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 GI Associates2025-12-09 09:56
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-01-09 00:49
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-09 12:15
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026868060_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-09 to 2026-03-09.
- Itemized billitemized_PA-473836.pdf8 pages
Itemised statement totalling $4323.00 across 3 lines.
- Medical recordrecords_PA-473836.pdf19 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:42 · 10179823
Other claims for this member
Same resolved identity
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
Notes document medical necessity.