CLM-2026-005737
Desert Diagnostic Imaging, Radiology. Service 2026-01-13 at outpatient hospital (POS 22). Received 2026-02-02.
Member
Resolved through the identity graph
- Member
- Mason Yang
- Member ID
- UHC-23214-93
- Date of birth
- 1979-11-19
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-403460
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8886
- Coverage period
- 2024-12-01 to present
- Deductible
- $557.86 of $1,000.0056%
- Out-of-pocket maximum
- $667.22 of $2,000.0033%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 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
- PA2025356384 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $219.00 | $120.45 | $120.45 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 1 | $2,217.00 | $1,219.35 | $590.99 | $628.36 | Paid |
| Totals | $2,436.00 | $1,339.80 | $711.44 | $628.36 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-992027
- 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-009014 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-13: N/A (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025356384 on file for 74177. | |
| 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 Imaging2026-01-13 11:00
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025356384_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-01-13 to 2026-04-13.
- Itemized billitemized_PA-992027.pdf4 pages
Itemised statement totalling $2436.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016787 | 2026-07-28 | Meadow Imaging Center | $2,378.00 | Denied |
| CLM-2026-007249 | 2026-01-28 | Northgate Internal Medicine Associates | $300.00 | Needs review |
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.