CLM-2026-005200
Mesa Imaging Center, Radiology. Service 2026-08-25 at outpatient hospital (POS 22). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Sara Jimenez
- Member ID
- none on golden record
- Date of birth
- 1968-08-07
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414842
- Relationship
- Child
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Mesa Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 6656135814
- Network
- Out of network
- Rendering NPI
- 6656135814
- Location
- Minneapolis, MN · TIN 75-3868074
- Authorisation / referral
- PA2026949993 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,473.00 | $662.85 | — | — | PendedIDQ |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $220.00 | $99.00 | — | — | PendedIDQ |
| Totals | $1,693.00 | $761.85 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-731913
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002323; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026949993 on file for 74177. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Mesa Imaging Center2026-08-25 09:27
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026949993_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-25 to 2026-11-23.
- Itemized billitemized_PA-731913.pdf6 pages
Itemised statement totalling $1693.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002323; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.