CLM-2026-007163
Valley Imaging Center, Radiology. Service 2026-05-18 at outpatient hospital (POS 22). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Rachel Watson
- Member ID
- UHC-77213-11
- Date of birth
- 1942-09-23
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-407308
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-6871
- Coverage period
- 2024-12-01 to present
- Deductible
- $495.30 of $2,500.0020%
- Out-of-pocket maximum
- $1,181.35 of $5,000.0024%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7696270280
- Network
- In network
- Rendering NPI
- 7696270280
- Location
- Scottsdale, AZ · TIN 61-0618370
- 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,271.00 | $1,799.05 | — | — | DeniedCO197 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $232.00 | $127.60 | — | — | DeniedCO197 |
| Totals | $3,503.00 | $1,926.65 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-115604
- 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-019966 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-18: NULL (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Valley Imaging Center (7696270280). | |
| 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: Valley Imaging Center2026-05-18 15:08
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-06-11 01:46
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-11 11:56
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-115604.pdf9 pages
Itemised statement totalling $3503.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 70553 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007719 | 2026-10-02 | Riverside Internal Medicine Associates | $318.00 | Approved |
| CLM-2026-006557 | 2026-05-28 | Mesa Internal Medicine Associates | $158.00 | Approved |
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.