CLM-2026-004829
Cornerstone Imaging Center, Radiology. Service 2025-12-29 at outpatient hospital (POS 22). Received 2026-02-04.
Member
Resolved through the identity graph
- Member
- Frank Thompson
- Member ID
- UHC-37893-53
- Date of birth
- 1992-04-06
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403583
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0825
- Coverage period
- 2024-03-01 to present
- Deductible
- $1,326.61 of $2,500.0053%
- Out-of-pocket maximum
- $1,047.76 of $5,000.0021%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9835477198
- Network
- In network
- Rendering NPI
- 9835477198
- Location
- Tampa, FL · TIN 89-9420622
- Authorisation / referral
- PA2025060314 / REF519740
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 | $3,384.00 | $1,861.20 | $1,310.95 | $550.25 | Paid |
| Totals | $3,384.00 | $1,861.20 | $1,310.95 | $550.25 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-186353
- 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-010177 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-29: NAVIGATE-HMO (HMO), effective 2024-03-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025060314 on file for 70553. | |
| Provider network | Pass | In-network provider Cornerstone Imaging Center (9835477198). | |
| 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: Cornerstone Imaging Center2025-12-29 18:31
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025060314_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-29 to 2026-03-29.
- Itemized billitemized_PA-186353.pdf2 pages
Itemised statement totalling $3384.00 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-2026-025036 | 2026-09-15 | Canyon Clinical Laboratories | $152.00 | Approved |
| CLM-2026-022953 | 2026-03-02 | Valley Primary Care Associates | $269.00 | Denied |
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.