CLM-2026-002914
Desert Imaging Center, Radiology. Service 2026-06-12 at outpatient hospital (POS 22). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Ray McDonald
- Member ID
- UHC-98853-73
- Date of birth
- 1965-06-24
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-408319
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- - PPO group -
- Coverage period
- 2021-06-01 to present
- Deductible
- $35.80 of $500.007%
- Out-of-pocket maximum
- $54.08 of $1,500.004%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 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 / 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 | $399.00 | $219.45 | $219.45 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $475.00 | $261.25 | $246.40 | $14.85 | Paid |
| Totals | $874.00 | $480.70 | $465.85 | $14.85 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-395974
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-039325 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-12: - (PPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 41 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Imaging Center2026-06-12 12:49
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-395974.pdf8 pages
Itemised statement totalling $874.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029093 | 2026-08-18 | Unity Counseling Center | $290.00 | 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.