CLM-2026-005053
Harbor Diagnostic Imaging, Radiology. Service 2026-01-25 at outpatient hospital (POS 22). Received 2026-01-30.
Member
Resolved through the identity graph
- Member
- Jeffrey Green
- Member ID
- UHC-73338-83
- Date of birth
- 1958-05-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421825
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5877
- Coverage period
- 2025-03-01 to present
- Deductible
- $415.10 of $500.0083%
- Out-of-pocket maximum
- $389.24 of $1,000.0039%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1623659319
- Network
- In network
- Rendering NPI
- 1623659319
- Location
- Houston, TX · TIN 54-3766877
- Authorisation / referral
- PA2026058993 / 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 | 77067 rev 0403 | Screening mammography, bilateral | 59 | 1 | 1 | $384.00 | $211.20 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | 59 | 1 | 1 | $2,247.00 | $1,235.85 | — | — | Review |
| Totals | $2,631.00 | $1,447.05 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-652150
- 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-008864 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-25: OPTIONS-PPO (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026058993 on file for 70553. | |
| Provider network | Pass | In-network provider Harbor Diagnostic Imaging (1623659319). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Harbor Diagnostic Imaging2026-01-25 14:51
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-30 00:21
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-30 15:50
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026058993_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-01-25 to 2026-04-25.
- Itemized billitemized_PA-652150.pdf4 pages
Itemised statement totalling $2631.00 across 2 lines.
- Medical recordrecords_PA-652150.pdf12 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028823 | 2026-08-08 | Mesa Reference Lab | $111.00 | Approved |
| CLM-2026-010322 | 2026-04-05 | Desert Internal Medicine Associates | $478.00 | 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
Bundled code pair; modifier 59 not supported by the operative note.