CLM-2026-003574
Cornerstone Imaging Center, Radiology. Service 2026-07-11 at outpatient hospital (POS 22). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Emma Silva
- Member ID
- UHC-22819-36
- Date of birth
- 1977-06-11
- Identity
- Verified7 records, confidence 0.98
- Claim record
- CLMCLM-422439
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8265
- Coverage period
- 2023-02-01 to present
- Deductible
- $2,737.20 of $3,500.0078%
- Out-of-pocket maximum
- $3,211.53 of $7,000.0046%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9835477198
- Network
- In network
- Rendering NPI
- 9835477198
- Location
- Tampa, FL · TIN 89-9420622
- Authorisation / referral
- PA2025933322 / 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 | $1,624.00 | $893.20 | — | — | Review |
| Totals | $1,624.00 | $893.20 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-325969
- 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-000644 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-07-11: UNKNOWN (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025933322 on file for 74177. | |
| Provider network | Pass | In-network provider Cornerstone Imaging Center (9835477198). | |
| 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: Cornerstone Imaging Center2026-07-11 18:43
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025933322_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-07-11 to 2026-10-09.
- Itemized billitemized_PA-325969.pdf7 pages
Itemised statement totalling $1624.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029524 | 2026-08-23 | Sunrise Behavioral Health | $173.00 | Approved |
| CLM-2026-005034 | 2026-08-16 | Lakeside Internal Medicine Associates | $288.00 | Approved |
| CLM-2026-003575 | 2026-07-11 | Cornerstone Imaging Center | $1,624.00 | Needs review |
| CLM-2026-007225 | 2025-12-28 | Desert Reference Lab | $139.00 | Approved |
| CLM-2026-007230 | 2025-11-30 | Meadow Clinical Laboratories | $125.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.