CLM-2026-003915
Valley Imaging Center, Radiology. Service 2026-02-02 at outpatient hospital (POS 22). Received 2026-02-12.
Member
Resolved through the identity graph
- Member
- Wei Washington
- Member ID
- UHC-27182-89
- Date of birth
- 1938-12-18
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-414438
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2179
- Coverage period
- 2021-03-01 to present
- Deductible
- $238.22 of $500.0048%
- Out-of-pocket maximum
- $147.04 of $1,000.0015%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7696270280
- Network
- In network
- Rendering NPI
- 7696270280
- Location
- Scottsdale, AZ · TIN 61-0618370
- Authorisation / referral
- PA2025338713 / 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 | $3,532.00 | $1,942.60 | $766.03 | $1,176.57 | Paid |
| Totals | $3,532.00 | $1,942.60 | $766.03 | $1,176.57 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-999629
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012530 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-02: NAVIGATE-HMO (HMO), effective 2021-03-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025338713 on file for 70553. | |
| Provider network | Pass | In-network provider Valley Imaging Center (7696270280). | |
| 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: Valley Imaging Center2026-02-02 16:15
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025338713_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-02-02 to 2026-05-03.
- Itemized billitemized_PA-999629.pdf5 pages
Itemised statement totalling $3532.00 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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033963 | 2026-04-05 | Unity Cardiovascular Associates | $1,279.00 | 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.