CLM-2026-000551
Valley Imaging Center, Radiology. Service 2026-04-23 at outpatient hospital (POS 22). Received 2026-06-05.
Member
Resolved through the identity graph
- Member
- Hannah Roberts
- Member ID
- UHC-68689-28
- Date of birth
- 1971-11-23
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420341
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5886
- Coverage period
- 2022-11-01 to present
- Deductible
- $2,716.44 of $3,500.0078%
- Out-of-pocket maximum
- $4,611.80 of $10,500.0044%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 5964910181
- Network
- In network
- Rendering NPI
- 5964910181
- Location
- Austin, TX · TIN 60-0192260
- Authorisation / referral
- PA2025725401 / REF795197
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 | $495.00 | $272.25 | $272.25 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,448.00 | $796.40 | $539.82 | $256.58 | Paid |
| Totals | $1,943.00 | $1,068.65 | $812.07 | $256.58 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-138915
- 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-013317 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-23: CORE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025725401 on file for 74177. | |
| Provider network | Pass | In-network provider Valley Imaging Center (5964910181). | |
| 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: Valley Imaging Center2026-04-23 17:24
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025725401_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-04-23 to 2026-07-22.
- Itemized billitemized_PA-138915.pdf8 pages
Itemised statement totalling $1943.00 across 2 lines.
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-2026-005389 | 2026-09-07 | Heritage Behavioral Health | $163.00 | Approved |
| CLM-2026-027488 | 2026-07-21 | Meadow Dermatology Clinic | $522.00 | Approved |
| CLM-2026-015718 | 2026-01-20 | Canyon Diagnostic Imaging | $769.00 | 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.