CLM-2026-001435
Riverside Diagnostic Imaging, Radiology. Service 2026-04-28 at outpatient hospital (POS 22). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- James Porter
- Member ID
- UHC-83196-09
- Date of birth
- 1948-06-18
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-431661
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4066
- Coverage period
- 2021-05-01 to present
- Deductible
- $627.92 of $2,500.0025%
- Out-of-pocket maximum
- $21.32 of $5,000.000%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6802768252
- Network
- In network
- Rendering NPI
- 6802768252
- Location
- Scottsdale, AZ · TIN 85-0998777
- Authorisation / referral
- PA2025868366 / 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 | $1,691.00 | $930.05 | $930.05 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $374.00 | $205.70 | $205.70 | $0.00 | Paid |
| Totals | $2,065.00 | $1,135.75 | $1,135.75 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-369748
- 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-005695 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-28: N/A (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025868366 on file for 74177. | |
| Provider network | Pass | In-network provider Riverside Diagnostic Imaging (6802768252). | |
| 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: Riverside Diagnostic Imaging2026-04-28 14:28
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025868366_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-04-28 to 2026-07-27.
- Itemized billitemized_PA-369748.pdf2 pages
Itemised statement totalling $2065.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028300 | 2026-06-23 | Unity Counseling Center | $187.00 | Approved |
| CLM-2026-033689 | 2026-05-29 | Northgate Internal Medicine Associates | $344.00 | Approved |
| CLM-2026-006117 | 2026-02-21 | Valley Reference Lab | $158.00 | 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.