CLM-2026-003755
Summit Imaging Center, Radiology. Service 2026-03-16 at outpatient hospital (POS 22). Received 2026-04-18.
Member
Resolved through the identity graph
- Member
- Heather Garza
- Member ID
- UHC-85505-93
- Date of birth
- 1983-04-15
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-411375
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9935
- Coverage period
- 2025-02-01 to present
- Deductible
- $782.46 of $1,500.0052%
- Out-of-pocket maximum
- $1,307.79 of $6,000.0022%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4562878908
- Network
- In network
- Rendering NPI
- 4562878908
- Location
- Minneapolis, MN · TIN 57-8653616
- Authorisation / referral
- PA2025645904 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,806.00 | $1,543.30 | — | — | Review |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 1 | $1,205.00 | $662.75 | — | — | Review |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | 25 | 1 | 1 | $351.00 | $193.05 | — | — | Review |
| Totals | $4,362.00 | $2,399.10 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-407235
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026564 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-16: OPTIONS-PPO (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025645904 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Summit Imaging Center (4562878908). | |
| Medical necessity | Review | CO50 | 70553, 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: Summit Imaging Center2026-03-16 14:48
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025645904_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-03-16 to 2026-06-14.
- Itemized billitemized_PA-407235.pdf3 pages
Itemised statement totalling $4362.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553, 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
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.