CLM-2026-006245
Desert Imaging Center, Radiology. Service 2026-06-14 at outpatient hospital (POS 22). Received 2026-06-27.
Member
Resolved through the identity graph
- Member
- Mason Castro
- Member ID
- UHC-01653-72
- Date of birth
- 1957-09-28
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-415766
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6170
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,579.21 of $2,500.0063%
- Out-of-pocket maximum
- $182.83 of $7,500.002%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3553360983
- Network
- In network
- Rendering NPI
- 3553360983
- Location
- Atlanta, GA · TIN 73-9549264
- Authorisation / referral
- PA2025577451 / REF832210
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 | $1,425.00 | $783.75 | $783.75 | $0.00 | Paid |
| Totals | $1,425.00 | $783.75 | $783.75 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-695442
- 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-012590 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-06-14: CORE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025577451 on file for 74177. | |
| Provider network | Pass | In-network provider Desert Imaging Center (3553360983). | |
| 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 Center2026-06-14 10:26
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025577451_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-06-14 to 2026-09-12.
- Itemized billitemized_PA-695442.pdf9 pages
Itemised statement totalling $1425.00 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-2026-006306 | 2026-06-26 | Riverside Medical Group | $356.00 | 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.