CLM-2026-005253
Desert Diagnostic Imaging, Radiology. Service 2025-12-14 at outpatient hospital (POS 22). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Ralph Peterson
- Member ID
- UHC-53260-05
- Date of birth
- 1995-08-04
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-427580
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-0505
- Coverage period
- 2025-04-01 to present
- Deductible
- $2,537.95 of $3,500.0073%
- Out-of-pocket maximum
- $1,392.24 of $14,000.0010%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3515366425
- Network
- In network
- Rendering NPI
- 3515366425
- Location
- Phoenix, AZ · TIN 68-2801174
- Authorisation / referral
- PA2025808404 / 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 | $2,509.00 | $1,379.95 | — | — | DeniedCO29 |
| Totals | $2,509.00 | $1,379.95 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-122698
- 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-006611 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-14: N/A (PPO), effective 2025-04-01. | |
| Timely filing | Fail | CO29 | Received 199 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025808404 on file for 70553. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (3515366425). | |
| 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: Desert Diagnostic Imaging2025-12-14 17:22
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-01 05:49
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-01 15:58
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025808404_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-14 to 2026-03-14.
- Itemized billitemized_PA-122698.pdf7 pages
Itemised statement totalling $2509.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 199 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006955 | 2026-07-20 | Harbor Family Practice | $16.00 | Approved |
| CLM-2026-014091 | 2025-12-23 | Lakeside Internal Medicine Associates | $75.00 | 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
Received after the timely-filing limit.