CLM-2026-000892
Canyon Diagnostic Imaging, Radiology. Service 2026-06-05 at outpatient hospital (POS 22). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Eugene Young
- Member ID
- UHC-39535-18
- Date of birth
- 1983-07-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-404007
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-6838
- Coverage period
- 2025-03-01 to present
- Deductible
- $1,201.71 of $1,500.0080%
- Out-of-pocket maximum
- $2,203.26 of $6,000.0037%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1352145704
- Network
- In network
- Rendering NPI
- 1352145704
- Location
- Atlanta, GA · TIN 24-1782323
- Authorisation / referral
- PA2026932065 / 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 | $408.00 | $224.40 | $224.40 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $1,663.00 | $914.65 | $326.12 | $588.53 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,448.00 | $1,346.40 | $403.92 | $942.48 | Paid |
| Totals | $4,519.00 | $2,485.45 | $954.44 | $1,531.01 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-851388
- 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-019039 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-05: N/A (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026932065 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (1352145704). | |
| 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: Canyon Diagnostic Imaging2026-06-05 16:44
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026932065_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-06-05 to 2026-09-03.
- Itemized billitemized_PA-851388.pdf6 pages
Itemised statement totalling $4519.00 across 3 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-2026-003586 | 2026-01-31 | Northgate Clinical Laboratories | $116.00 | 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.