CLM-2026-000312
Northgate Imaging Center, Radiology. Service 2025-12-14 at outpatient hospital (POS 22). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Gloria Ross
- Member ID
- UHC-95778-74
- Date of birth
- 1983-08-24
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-419181
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3774
- Coverage period
- 2021-10-01 to present
- Deductible
- $1,709.34 of $2,500.0068%
- Out-of-pocket maximum
- $3,440.02 of $10,000.0034%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3050464585
- Network
- Out of network
- Rendering NPI
- 3050464585
- Location
- San Diego, CA · TIN 61-2250278
- Authorisation / referral
- none / 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 | $1,961.00 | $882.45 | — | — | DeniedCO197 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $231.00 | $103.95 | — | — | DeniedCO197 |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 1 | $2,704.00 | $1,216.80 | — | — | DeniedCO197 |
| Totals | $4,896.00 | $2,203.20 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-187280
- 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-001638 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-14: MEDICARE-ADV-B (MA), effective 2021-10-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177, 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Northgate Imaging Center2025-12-14 10:00
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-06 02:37
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-187280.pdf6 pages
Itemised statement totalling $4896.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 74177, 70553 require precertification; no authorisation number on the claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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
Precertification required and absent.