CLM-2026-003082
Canyon Diagnostic Imaging, Radiology. Service 2026-05-15 at outpatient hospital (POS 22). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Kevin Turner
- Member ID
- UHC-30904-19
- Date of birth
- 1981-03-07
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-403534
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5201
- Coverage period
- 2022-05-01 to present
- Deductible
- $1,811.75 of $3,500.0052%
- Out-of-pocket maximum
- $1,638.05 of $7,000.0023%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6871661313
- Network
- In network
- Rendering NPI
- 6871661313
- Location
- Tampa, FL · TIN 87-4174394
- Authorisation / referral
- PA2025058844 / 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 | $255.00 | $140.25 | $140.25 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,589.00 | $1,423.95 | $1,423.95 | $0.00 | Paid |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $2,141.00 | $1,177.55 | $440.10 | $737.45 | Paid |
| Totals | $4,985.00 | $2,741.75 | $2,004.30 | $737.45 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-555788
- 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-033571 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-15: SELECT-EPO (EPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025058844 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (6871661313). | |
| 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 Imaging2026-05-15 10:41
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025058844_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-05-15 to 2026-08-13.
- Itemized billitemized_PA-555788.pdf7 pages
Itemised statement totalling $4985.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019237 | 2026-08-21 | Canyon Primary Care Associates | $19.00 | 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.