CLM-2026-001259
Desert Imaging Center, Radiology. Service 2026-03-17 at outpatient hospital (POS 22). Received 2026-04-25.
Member
Resolved through the identity graph
- Member
- Diego Dominguez
- Member ID
- UHC-90646-41
- Date of birth
- 1985-01-01
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-431941
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8149
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,186.55 of $3,500.0034%
- Out-of-pocket maximum
- $384.66 of $10,500.004%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3553360983
- Network
- In network
- Rendering NPI
- 3553360983
- Location
- Atlanta, GA · TIN 73-9549264
- Authorisation / referral
- PA2025513275 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,307.00 | $718.85 | $718.85 | $0.00 | Paid |
| Totals | $1,307.00 | $718.85 | $718.85 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-903047
- 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-026057 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-17: OPTIONS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025513275 on file for 74177. | |
| Provider network | Pass | In-network provider Desert Imaging Center (3553360983). | |
| 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: Desert Imaging Center2026-03-17 13:40
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Prior auth letterPA2025513275_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-03-17 to 2026-06-15.
- Itemized billitemized_PA-903047.pdf2 pages
Itemised statement totalling $1307.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030974 | 2026-05-20 | Sunrise Clinical Laboratories | $63.00 | Approved |
| CLM-2026-019273 | 2026-03-10 | Sunrise Medical Group | $558.00 | Needs review |
| CLM-2026-019272 | 2026-03-10 | Sunrise Medical Group | $558.00 | 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.