CLM-2026-002101
Desert Imaging Center, Radiology. Service 2026-08-23 at outpatient hospital (POS 22). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Sandra Owens
- Member ID
- UHC-89246-62
- Date of birth
- 1978-11-16
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-405480
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3971
- Coverage period
- 2025-10-01 to present
- Deductible
- $680.38 of $1,000.0068%
- Out-of-pocket maximum
- $1,118.08 of $4,000.0028%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 3 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
- none / REF521377
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 | $427.00 | $234.85 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $203.00 | $111.65 | — | — | Review |
| Totals | $630.00 | $346.50 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-441686
- 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-003380 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-23: NAVIGATE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 10 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 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 | Review | CO16 | Documentation incomplete: “Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled. Note dic”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Imaging Center2026-08-23 12:20
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-02 04:42
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-02 15:20
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-441686.pdf5 pages
Itemised statement totalling $630.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled. Note dic”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.