CLM-2026-004884
Heritage Imaging Center, Radiology. Service 2026-05-17 at outpatient hospital (POS 22). Received 2026-06-26.
Member
Resolved through the identity graph
- Member
- Cheryl Campbell
- Member ID
- UHC-77477-89
- Date of birth
- 1989-09-23
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-406492
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3912
- Coverage period
- 2022-05-01 to present
- Deductible
- $2,872.60 of $3,500.0082%
- Out-of-pocket maximum
- $2,975.54 of $10,500.0028%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4466693437
- Network
- In network
- Rendering NPI
- 4466693437
- Location
- Atlanta, GA · TIN 36-7680074
- Authorisation / referral
- none / 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 | $3,138.00 | $1,725.90 | — | — | DeniedCO197 |
| Totals | $3,138.00 | $1,725.90 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-810774
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020737 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-17: NULL (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Heritage Imaging Center (4466693437). | |
| 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: Heritage Imaging Center2026-05-17 13:47
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-26 03:50
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-26 14:08
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-810774.pdf7 pages
Itemised statement totalling $3138.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 70553 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.