CLM-2026-001345
Valley Imaging Center, Radiology. Service 2026-09-15 at outpatient hospital (POS 22). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Alan Pierce
- Member ID
- UHC-35222-28
- Date of birth
- 1970-01-22
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-420049
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4301
- Coverage period
- 2024-02-01 to 2026-08-05
- Deductible
- $1,237.91 of $2,500.0050%
- Out-of-pocket maximum
- $1,851.21 of $7,500.0025%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 12 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
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $413.00 | $227.15 | — | — | DeniedCO27 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $369.00 | $202.95 | — | — | DeniedCO27 |
| Totals | $782.00 | $430.10 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-147792
- 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-013887 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-15 is after coverage terminated on 2026-08-05. 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 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 Center2026-09-15 14:34
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-03 05:48
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-03 10:43
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-147792.pdf5 pages
Itemised statement totalling $782.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-15 is after coverage terminated on 2026-08-05.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031369 | 2026-01-22 | Summit Regional Medical Center | $1,089.00 | Approved |
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.