CLM-2026-003573
Mesa Imaging Center, Radiology. Service 2026-09-13 at outpatient hospital (POS 22). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Dylan Robinson
- Member ID
- UHC-25806-40
- Date of birth
- 2007-07-15
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-419575
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0634
- Coverage period
- 2023-11-01 to present
- Deductible
- $1,076.84 of $1,500.0072%
- Out-of-pocket maximum
- $285.84 of $3,000.0010%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 6656135814
- Network
- Out of network
- Rendering NPI
- 6656135814
- Location
- Minneapolis, MN · TIN 75-3868074
- 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 | $330.00 | $148.50 | $148.50 | $0.00 | Paid |
| Totals | $330.00 | $148.50 | $148.50 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-971402
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009940 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-13: MEDICARE-ADV-A (MA), effective 2023-11-01. | |
| Timely filing | Pass | Received 4 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Mesa Imaging Center2026-09-13 18:53
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-971402.pdf4 pages
Itemised statement totalling $330.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033815 | 2026-05-15 | Sunrise Medical Group | $66.00 | Approved |
| CLM-2026-017634 | 2026-03-13 | Canyon Regional Medical Center | $857.00 | 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.