CLM-2026-007140
Canyon Diagnostic Imaging, Radiology. Service 2026-08-12 at outpatient hospital (POS 22). Received 2026-09-21.
Member
Resolved through the identity graph
- Member
- Heather Vazquez
- Member ID
- none on golden record
- Date of birth
- 1986-11-05
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-418900
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-4855
- Coverage period
- 2021-03-01 to present
- Deductible
- $131.54 of $1,000.0013%
- Out-of-pocket maximum
- $614.16 of $3,000.0020%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 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
- PA2025974196 / 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 | $1,880.00 | $1,034.00 | $901.57 | $132.43 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | 25 | 1 | 1 | $333.00 | $183.15 | $36.63 | $146.52 | Paid |
| Totals | $2,213.00 | $1,217.15 | $938.20 | $278.95 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-210894
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-044724 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-08-12: MEDICARE-ADV-A (MA), effective 2021-03-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025974196 on file for 74177. | |
| 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 Imaging2026-08-12 15:58
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025974196_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-12 to 2026-11-10.
- Itemized billitemized_PA-210894.pdf5 pages
Itemised statement totalling $2213.00 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 13:43Eligibility: Active on 2026-08-12: MEDICARE-ADV-A (MA), effective 2021-03-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011799 | 2026-09-12 | Mesa Family Practice | $351.00 | 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.