CLM-2026-006717
Evergreen Diagnostic Imaging, Radiology. Service 2026-05-20 at outpatient hospital (POS 22). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Zachary Lawrence
- Member ID
- UHC-98739-62
- Date of birth
- 2004-01-13
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-422514
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-2285
- Coverage period
- 2024-03-01 to 2026-08-24
- Deductible
- $27.69 of $1,000.003%
- Out-of-pocket maximum
- $843.47 of $3,000.0028%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 7098075170
- Network
- In network
- Rendering NPI
- 7098075170
- Location
- Atlanta, GA · TIN 75-1814880
- Authorisation / referral
- none / 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 | $1,263.00 | $694.65 | — | — | DeniedCO197 |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1,2 | $380.00 | $209.00 | — | — | DeniedCO197 |
| Totals | $1,643.00 | $903.65 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-704840
- 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-032588 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-20: UNKNOWN (PPO), effective 2024-03-01, terms 2026-08-24. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (7098075170). | |
| 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: Evergreen Diagnostic Imaging2026-05-20 18:38
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-05-27 06:03
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-704840.pdf6 pages
Itemised statement totalling $1643.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 74177 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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
Precertification required and absent.