CLM-2026-002539
Harbor Diagnostic Imaging, Radiology. Service 2026-01-17 at outpatient hospital (POS 22). Received 2026-05-22.
Member
Resolved through the identity graph
- Member
- Austin Evans
- Member ID
- UHC-08309-61
- Date of birth
- 1974-06-26
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-425872
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4068
- Coverage period
- 2022-03-01 to present
- Deductible
- $872.40 of $1,000.0087%
- Out-of-pocket maximum
- $730.65 of $2,000.0037%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1623659319
- Network
- In network
- Rendering NPI
- 1623659319
- Location
- Houston, TX · TIN 54-3766877
- Authorisation / referral
- PA2026229917 / REF240267
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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,006.00 | $1,653.30 | — | — | DeniedCO29 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $292.00 | $160.60 | — | — | DeniedCO29 |
| Totals | $3,298.00 | $1,813.90 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-936579
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031816 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-17: CORE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Fail | CO29 | Received 125 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026229917 on file for 70553. | |
| Provider network | Pass | In-network provider Harbor Diagnostic Imaging (1623659319). | |
| 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: Harbor Diagnostic Imaging2026-01-17 16:04
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-05-22 06:15
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-22 09:30
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026229917_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-17 to 2026-04-17.
- Itemized billitemized_PA-936579.pdf6 pages
Itemised statement totalling $3298.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 125 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.