CLM-2026-001742
Northgate Imaging Center, Radiology. Service 2025-12-22 at outpatient hospital (POS 22). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Ralph Myers
- Member ID
- UHC-48858-85
- Date of birth
- 1966-04-05
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-416065
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6653
- Coverage period
- 2023-09-01 to present
- Deductible
- $346.17 of $500.0069%
- Out-of-pocket maximum
- $8.15 of $1,500.001%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3050464585
- Network
- Out of network
- Rendering NPI
- 3050464585
- Location
- San Diego, CA · TIN 61-2250278
- 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 | $247.00 | $111.15 | — | — | DeniedCO204 |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | 25 | 1 | 1 | $324.00 | $145.80 | — | — | DeniedCO204 |
| Totals | $571.00 | $256.95 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-542433
- 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-002827 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2025-12-22: SELECT-EPO (EPO), effective 2023-09-01. | |
| 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 | Fail | CO204 | Billing provider 3050464585 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Northgate Imaging Center2025-12-22 11:26
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-09 04:39
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-09 15:30
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-542433.pdf2 pages
Itemised statement totalling $571.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 3050464585 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032287 | 2026-04-27 | Harbor Family Practice | $310.00 | 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
No out-of-network benefit on this plan.