CLM-2026-005526
Summit Diagnostic Imaging, Radiology. Service 2025-11-24 at outpatient hospital (POS 22). Received 2026-01-03.
Member
Resolved through the identity graph
- Member
- Amanda Shaw
- Member ID
- UHC-91321-72
- Date of birth
- 1966-03-05
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-414103
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9009
- Coverage period
- 2024-12-01 to present
- Deductible
- $2,166.88 of $2,500.0087%
- Out-of-pocket maximum
- $1,916.07 of $7,500.0026%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8935049519
- Network
- In network
- Rendering NPI
- 8935049519
- Location
- Los Angeles, CA · TIN 90-8085018
- Authorisation / referral
- none / REF954072
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 | $307.00 | $168.85 | $168.85 | $0.00 | Paid |
| Totals | $307.00 | $168.85 | $168.85 | $0.00 | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-277237
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000905 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-24: NAVIGATE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Diagnostic Imaging (8935049519). | |
| 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: Summit Diagnostic Imaging2025-11-24 10:46
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Itemized billitemized_PA-277237.pdf4 pages
Itemised statement totalling $307.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033991 | 2026-09-21 | Desert Imaging Center | $3,071.00 | Approved |
| CLM-2026-031024 | 2026-09-17 | Meadow Physical Therapy | $456.00 | Approved |
| CLM-2026-010185 | 2026-06-18 | Mesa Family Practice | $30.00 | Approved |
| CLM-2026-016778 | 2026-03-01 | Unity Medical Group | $244.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.