CLM-2026-004415
Summit Diagnostic Imaging, Radiology. Service 2026-09-07 at outpatient hospital (POS 22). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Judy Rivera
- Member ID
- UHC-37285-52
- Date of birth
- 1960-05-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411314
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8564
- Coverage period
- 2022-05-01 to present
- Deductible
- $2,025.46 of $2,500.0081%
- Out-of-pocket maximum
- $2,056.70 of $5,000.0041%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8935049519
- Network
- In network
- Rendering NPI
- 8935049519
- Location
- Los Angeles, CA · TIN 90-8085018
- Authorisation / referral
- PA2026187625 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $216.00 | $118.80 | $118.80 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $2,208.00 | $1,214.40 | $613.34 | $601.06 | Paid |
| Totals | $2,424.00 | $1,333.20 | $732.14 | $601.06 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-283247
- 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-021595 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-07: SELECT-EPO (EPO), effective 2022-05-01. | |
| 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 PA2026187625 on file for 74177. | |
| Provider network | Pass | In-network provider Summit Diagnostic Imaging (8935049519). | |
| 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: Summit Diagnostic Imaging2026-09-07 18:20
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026187625_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-09-07 to 2026-12-06.
- Itemized billitemized_PA-283247.pdf6 pages
Itemised statement totalling $2424.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014461 | 2026-06-10 | Heritage Medical Group | $294.00 | Approved |
| CLM-2026-028777 | 2026-04-22 | Valley Internal Medicine Associates | $417.00 | Approved |
| CLM-2026-009279 | 2026-02-27 | Evergreen Medical Group | $232.00 | 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.