CLM-2026-003939
Harbor Diagnostic Imaging, Radiology. Service 2026-05-23 at outpatient hospital (POS 22). Received 2026-07-03.
Member
Resolved through the identity graph
- Member
- Martha Ellis
- Member ID
- UHC-36344-06
- Date of birth
- 1988-04-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-425961
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6716
- Coverage period
- 2023-04-01 to present
- Deductible
- $252.90 of $1,000.0025%
- Out-of-pocket maximum
- $1,078.51 of $3,000.0036%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1623659319
- Network
- In network
- Rendering NPI
- 1623659319
- Location
- Houston, TX · TIN 54-3766877
- Authorisation / referral
- PA2026228864 / 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 | $2,025.00 | $1,113.75 | $820.43 | $293.32 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $284.00 | $156.20 | $31.24 | $124.96 | Paid |
| Totals | $2,309.00 | $1,269.95 | $851.67 | $418.28 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-607438
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008522 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-23: SELECT-EPO (EPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026228864 on file for 70553. | |
| Provider network | Pass | In-network provider Harbor Diagnostic Imaging (1623659319). | |
| 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: Harbor Diagnostic Imaging2026-05-23 11:34
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026228864_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-05-23 to 2026-08-21.
- Itemized billitemized_PA-607438.pdf3 pages
Itemised statement totalling $2309.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024671 | 2026-04-20 | Lakeside Orthopedic Specialists | $49,137.00 | Needs review |
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.