CLM-2026-004914
Canyon Diagnostic Imaging, Radiology. Service 2026-03-10 at outpatient hospital (POS 22). Received 2026-03-17.
Member
Resolved through the identity graph
- Member
- Juan Lane
- Member ID
- UHC-46484-18
- Date of birth
- 1965-04-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-418771
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7109
- Coverage period
- 2024-02-01 to present
- Deductible
- $242.29 of $2,500.0010%
- Out-of-pocket maximum
- $4,371.28 of $10,000.0044%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6871661313
- Network
- In network
- Rendering NPI
- 6871661313
- Location
- Tampa, FL · TIN 87-4174394
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $393.00 | $216.15 | $216.15 | $0.00 | Paid |
| Totals | $393.00 | $216.15 | $216.15 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-491741
- 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-005741 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-10: NULL (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (6871661313). | |
| 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: Canyon Diagnostic Imaging2026-03-10 15:34
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-491741.pdf6 pages
Itemised statement totalling $393.00 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-2026-012473 | 2025-12-06 | Lakeside Endocrine Associates | $240.00 | 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.