CLM-2026-002392
Canyon Diagnostic Imaging, Radiology. Service 2026-08-19 at outpatient hospital (POS 22). Received 2026-10-02.
Member
Resolved through the identity graph
- Member
- Jose Jensen
- Member ID
- UHC-42670-96
- Date of birth
- 1953-01-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431452
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6226
- Coverage period
- 2022-08-01 to present
- Deductible
- $353.87 of $500.0071%
- Out-of-pocket maximum
- $159.08 of $2,000.008%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8055565153
- Network
- In network
- Rendering NPI
- 8055565153
- Location
- Atlanta, GA · TIN 44-7708549
- Authorisation / referral
- PA2025058469 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $198.00 | $108.90 | $108.90 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,494.00 | $1,371.70 | $437.57 | $934.13 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $583.00 | $320.65 | $96.20 | $224.45 | Paid |
| Totals | $3,275.00 | $1,801.25 | $642.67 | $1,158.58 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-747579
- 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-003614 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-19: UNKNOWN (PPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025058469 on file for 70553. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (8055565153). | |
| 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: Canyon Diagnostic Imaging2026-08-19 17:31
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025058469_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-08-19 to 2026-11-17.
- Itemized billitemized_PA-747579.pdf7 pages
Itemised statement totalling $3275.00 across 3 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-2026-033293 | 2026-09-15 | Canyon Reference Lab | $40.00 | Approved |
| CLM-2026-009118 | 2025-12-22 | Unity Digestive Health Center | $219.00 | 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.