CLM-2026-000319
Mesa Imaging Center, Radiology. Service 2026-04-30 at outpatient hospital (POS 22). Received 2026-05-15.
Member
Resolved through the identity graph
- Member
- Wei Garza
- Member ID
- UHC-61834-78
- Date of birth
- 1973-05-15
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-400087
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5121
- Coverage period
- 2025-10-01 to 2026-06-23
- Deductible
- $121.63 of $500.0024%
- Out-of-pocket maximum
- $479.10 of $1,000.0048%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 6656135814
- Network
- Out of network
- Rendering NPI
- 6656135814
- Location
- Minneapolis, MN · TIN 75-3868074
- 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $349.00 | $157.05 | $157.05 | $0.00 | Paid |
| Totals | $349.00 | $157.05 | $157.05 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-865677
- 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-019651 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-30: NULL (PPO), effective 2025-10-01, terms 2026-06-23. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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: Mesa Imaging Center2026-04-30 17:05
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-865677.pdf8 pages
Itemised statement totalling $349.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021695 | 2026-04-05 | Heritage Behavioral Health | $254.00 | Approved |
| CLM-2026-028208 | 2026-02-06 | Sunrise Behavioral Health | $140.00 | 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.