CLM-2026-005159
Heritage Imaging Center, Radiology. Service 2026-03-03 at outpatient hospital (POS 22). Received 2026-04-20.
Member
Resolved through the identity graph
- Member
- Joshua Diaz
- Member ID
- UHC-17950-82
- Date of birth
- 1988-04-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402938
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2926
- Coverage period
- 2024-10-01 to present
- Deductible
- $2,191.10 of $2,500.0088%
- Out-of-pocket maximum
- $2,353.91 of $10,000.0024%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 14 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $227.00 | $124.85 | — | — | DeniedCO18 |
| Totals | $227.00 | $124.85 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-119309
- 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-024657 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-03: SELECT-EPO (EPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 48 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-005158: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-03-03 11:08
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-04-20 00:44
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-20 11:05
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-119309.pdf3 pages
Itemised statement totalling $227.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-005158: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005158 | 2026-03-03 | Heritage Imaging Center | $227.00 | Approved |
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
Different billing provider; separately payable.