CLM-2026-005624
Desert Imaging Center, Radiology. Service 2026-01-12 at outpatient hospital (POS 22). Received 2026-02-13.
Member
Resolved through the identity graph
- Member
- Christina Sullivan
- Member ID
- UHC-85355-99
- Date of birth
- 1970-12-19
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-409736
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2119
- Coverage period
- 2023-06-01 to present
- Deductible
- $66.30 of $1,000.007%
- Out-of-pocket maximum
- $335.87 of $3,000.0011%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7235030955
- Network
- In network
- Rendering NPI
- 7235030955
- Location
- San Diego, CA · TIN 44-8505123
- Authorisation / referral
- PA2025217735 / 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 | $1,257.00 | $691.35 | $691.35 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $233.00 | $128.15 | $128.15 | $0.00 | Paid |
| Totals | $1,490.00 | $819.50 | $819.50 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-242374
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006887 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-12: MEDICARE-ADV-A (MA), effective 2023-06-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025217735 on file for 74177. | |
| Provider network | Pass | In-network provider Desert Imaging Center (7235030955). | |
| 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 Imaging Center2026-01-12 10:35
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025217735_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-01-12 to 2026-04-12.
- Itemized billitemized_PA-242374.pdf5 pages
Itemised statement totalling $1490.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.