CLM-2026-002398
Evergreen Diagnostic Imaging, Radiology. Service 2026-07-19 at outpatient hospital (POS 22). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Katherine Dixon
- Member ID
- UHC-09672-15
- Date of birth
- 1989-07-28
- Identity
- Verified6 records, confidence 0.94
- Claim record
- CLMCLM-412984
- Relationship
- Child, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1423
- Coverage period
- 2024-09-01 to present
- Deductible
- $435.36 of $1,000.0044%
- Out-of-pocket maximum
- $413.39 of $2,000.0021%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 4970897466
- Network
- In network
- Rendering NPI
- 4970897466
- Location
- Charlotte, NC · TIN 79-7771528
- Authorisation / referral
- PA2026567267 / 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 | $399.00 | $219.45 | $219.45 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 1 | $1,875.00 | $1,031.25 | $482.40 | $548.85 | Paid |
| Totals | $2,274.00 | $1,250.70 | $701.85 | $548.85 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-943213
- 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-007502 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-07-19: SELECT-EPO (EPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026567267 on file for 74177. | |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (4970897466). | |
| 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: Evergreen Diagnostic Imaging2026-07-19 14:34
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026567267_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-07-19 to 2026-10-17.
- Itemized billitemized_PA-943213.pdf9 pages
Itemised statement totalling $2274.00 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-2026-003304 | 2026-08-08 | Riverside Orthopedic Specialists | $240.00 | Approved |
| CLM-2026-029185 | 2026-08-23 | Lakeside Dermatology Clinic | $296.00 | Approved |
| CLM-2026-026528 | 2026-06-05 | Northgate Internal Medicine Associates | $332.00 | 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.