CLM-2026-000964
Canyon Diagnostic Imaging, Radiology. Service 2026-09-05 at outpatient hospital (POS 22). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Li Li
- Member ID
- UHC-11038-16
- Date of birth
- 2003-12-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425745
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7745
- Coverage period
- 2021-02-01 to 2026-02-12
- Deductible
- $149.30 of $2,500.006%
- Out-of-pocket maximum
- $3,183.75 of $10,000.0032%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8055565153
- Network
- In network
- Rendering NPI
- 8055565153
- Location
- Atlanta, GA · TIN 44-7708549
- 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 | $318.00 | $174.90 | — | — | DeniedCO27 |
| Totals | $318.00 | $174.90 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-934911
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023628 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-05 is after coverage terminated on 2026-02-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 18 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 | Pass | In-network provider Canyon Diagnostic Imaging (8055565153). | |
| 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 Imaging2026-09-05 12:19
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-23 05:47
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-23 16:58
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-934911.pdf3 pages
Itemised statement totalling $318.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-05 is after coverage terminated on 2026-02-12.
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
Service after coverage termination.