CLM-2026-005044
Valley Imaging Center, Radiology. Service 2026-01-24 at outpatient hospital (POS 22). Received 2026-02-02.
Member
Resolved through the identity graph
- Member
- Diane Cox
- Member ID
- UHC-99365-35
- Date of birth
- 1947-05-26
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426293
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-6817
- Coverage period
- 2024-09-01 to present
- Deductible
- $12.30 of $500.002%
- Out-of-pocket maximum
- $237.68 of $1,000.0024%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7696270280
- Network
- In network
- Rendering NPI
- 7696270280
- Location
- Scottsdale, AZ · TIN 61-0618370
- Authorisation / referral
- PA2025062913 / 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 | $3,005.00 | $1,652.75 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $133.00 | $73.15 | — | — | Review |
| Totals | $3,138.00 | $1,725.90 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-984090
- 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-001337 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-24: NULL (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025062913 on file for 70553. | |
| Provider network | Pass | In-network provider Valley Imaging Center (7696270280). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; 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: Valley Imaging Center2026-01-24 10:52
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-02-02 02:24
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-02 08:58
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025062913_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-24 to 2026-04-24.
- Itemized billitemized_PA-984090.pdf4 pages
Itemised statement totalling $3138.00 across 2 lines.
- Medical recordrecords_PA-984090.pdf11 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030670 | 2025-12-15 | Sunrise Dermatology Clinic | $160.00 | Approved |
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
Notes document medical necessity.