CLM-2026-000664
Harbor Imaging Center, Radiology. Service 2025-12-05 at outpatient hospital (POS 22). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Patricia Ross
- Member ID
- UHC-68744-18
- Date of birth
- 1949-05-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-424065
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6642
- Coverage period
- 2021-03-01 to present
- Deductible
- $195.94 of $1,500.0013%
- Out-of-pocket maximum
- $607.97 of $3,000.0020%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3423421452
- Network
- In network
- Rendering NPI
- 3423421452
- Location
- Denver, CO · TIN 47-9293451
- Authorisation / referral
- PA2026456616 / REF837573
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $115.00 | $63.25 | $63.25 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 1 | $3,159.00 | $1,737.45 | $1,389.80 | $347.65 | Paid |
| Totals | $3,274.00 | $1,800.70 | $1,453.05 | $347.65 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-984302
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002162 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-05: CORE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026456616 on file for 70553. | |
| Provider network | Pass | In-network provider Harbor Imaging Center (3423421452). | |
| 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: Harbor Imaging Center2025-12-05 12:05
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026456616_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2025-12-05 to 2026-03-05.
- Itemized billitemized_PA-984302.pdf6 pages
Itemised statement totalling $3274.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018262 | 2026-04-14 | Canyon Medical Group | $483.00 | 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.