CLM-2026-007104
Canyon Diagnostic Imaging, Radiology. Service 2026-02-05 at outpatient hospital (POS 22). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Randy Meyer
- Member ID
- UHC-67823-81
- Date of birth
- 1955-09-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428487
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-8945
- Coverage period
- 2022-01-01 to present
- Deductible
- $360.89 of $2,500.0014%
- Out-of-pocket maximum
- $1,888.74 of $10,000.0019%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6871661313
- Network
- In network
- Rendering NPI
- 6871661313
- Location
- Tampa, FL · TIN 87-4174394
- 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $241.00 | $132.55 | $132.55 | $0.00 | Paid |
| Totals | $241.00 | $132.55 | $132.55 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-947149
- 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-018229 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-05: - (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 31 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 Canyon Diagnostic Imaging (6871661313). | |
| 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: Canyon Diagnostic Imaging2026-02-05 10:55
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Itemized billitemized_PA-947149.pdf6 pages
Itemised statement totalling $241.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 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.