CLM-2026-008019
Summit Diagnostic Imaging, Radiology. Service 2026-01-01 at outpatient hospital (POS 22). Received 2026-01-26.
Member
Resolved through the identity graph
- Member
- Marcus Fernandez
- Member ID
- UHC-69524-07
- Date of birth
- 1997-10-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432752
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9519
- Coverage period
- 2022-06-01 to present
- Deductible
- $438.17 of $1,500.0029%
- Out-of-pocket maximum
- $2,039.76 of $4,500.0045%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8935049519
- Network
- In network
- Rendering NPI
- 8935049519
- Location
- Los Angeles, CA · TIN 90-8085018
- Authorisation / referral
- PA2026310424 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $359.00 | $197.45 | $197.45 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,444.00 | $794.20 | $794.20 | $0.00 | Paid |
| Totals | $1,803.00 | $991.65 | $991.65 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-653054
- 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-004845 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-01: OPTIONS-PPO (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026310424 on file for 74177. | |
| Provider network | Pass | In-network provider Summit Diagnostic Imaging (8935049519). | |
| 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: Summit Diagnostic Imaging2026-01-01 14:24
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026310424_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-01-01 to 2026-04-01.
- Itemized billitemized_PA-653054.pdf9 pages
Itemised statement totalling $1803.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031266 | 2026-02-18 | Pinecrest Bone and Joint Center | $153.00 | Approved |
| CLM-2026-027400 | 2025-12-09 | Mesa Family Practice | $426.00 | 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.