CLM-2026-003527
Desert Diagnostic Imaging, Radiology. Service 2026-08-11 at outpatient hospital (POS 22). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Judy Alexander
- Member ID
- UHC-75403-09
- Date of birth
- 1990-09-12
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-406289
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8030
- Coverage period
- 2022-11-01 to 2026-04-05
- Deductible
- $461.96 of $1,500.0031%
- Out-of-pocket maximum
- $1,359.71 of $4,500.0030%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 2571625872
- Network
- In network
- Rendering NPI
- 2571625872
- Location
- Dallas, TX · TIN 43-0454627
- Authorisation / referral
- PA2025004038 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,480.00 | $814.00 | — | — | DeniedCO27 |
| Totals | $1,480.00 | $814.00 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-709657
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021600 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-11 is after coverage terminated on 2026-04-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025004038 on file for 74177. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (2571625872). | |
| Medical necessity | Review | CO50 | 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Diagnostic Imaging2026-08-11 17:31
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
- SystemSystem: Claims system2026-09-05 03:55
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-05 09:17
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025004038_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-11 to 2026-11-09.
- Itemized billitemized_PA-709657.pdf9 pages
Itemised statement totalling $1480.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-11 is after coverage terminated on 2026-04-05. Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
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
Service after coverage termination.