CLM-2026-004250
Harbor Imaging Center, Radiology. Service 2025-12-21 at outpatient hospital (POS 22). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Roy Price
- Member ID
- UHC-50198-86
- Date of birth
- 1981-03-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416653
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3499
- Coverage period
- 2023-03-01 to present
- Deductible
- $62.18 of $500.0012%
- Out-of-pocket maximum
- $569.87 of $1,500.0038%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3423421452
- Network
- In network
- Rendering NPI
- 3423421452
- Location
- Denver, CO · TIN 47-9293451
- Authorisation / referral
- PA2025186942 / 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 | $2,371.00 | $1,304.05 | — | — | Review |
| Totals | $2,371.00 | $1,304.05 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-344646
- 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-003203 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-21: CHOICE-PLUS-PPO (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025186942 on file for 74177. | |
| Provider network | Pass | In-network provider Harbor Imaging Center (3423421452). | |
| 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: Harbor Imaging Center2025-12-21 17:39
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Prior auth letterPA2025186942_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-12-21 to 2026-03-21.
- Itemized billitemized_PA-344646.pdf7 pages
Itemised statement totalling $2371.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 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.