CLM-2026-007168
Evergreen Diagnostic Imaging, Radiology. Service 2026-03-02 at outpatient hospital (POS 22). Received 2026-03-13.
Member
Resolved through the identity graph
- Member
- Ryan Duncan
- Member ID
- UHC-30657-74
- Date of birth
- 2002-11-20
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-407163
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3170
- Coverage period
- 2021-09-01 to present
- Deductible
- $341.57 of $1,500.0023%
- Out-of-pocket maximum
- $2,075.35 of $4,500.0046%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- 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
- PA2025354324 / 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 | $3,447.00 | $1,895.85 | $1,232.17 | $663.68 | Paid |
| Totals | $3,447.00 | $1,895.85 | $1,232.17 | $663.68 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-415839
- 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-001461 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-02: CHOICE-PLUS-PPO (PPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025354324 on file for 70553. | |
| 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 Imaging2026-03-02 09:35
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025354324_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-03-02 to 2026-05-31.
- Itemized billitemized_PA-415839.pdf5 pages
Itemised statement totalling $3447.00 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-2026-027256 | 2026-04-16 | Heritage Physical Therapy | $140.00 | Denied |
| CLM-2026-007169 | 2026-03-02 | Evergreen Diagnostic Imaging | $3,447.00 | Denied |
| CLM-2026-009928 | 2025-09-05 | Heritage Community Hospital | $4,570.00 | Denied |
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.