CLM-2026-008486
Desert Diagnostic Imaging, Radiology. Service 2026-09-10 at outpatient hospital (POS 22). Received 2026-09-30.
Member
Resolved through the identity graph
- Member
- Nathan Greene
- Member ID
- UHC-46806-74
- Date of birth
- 1999-07-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-429112
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5726
- Coverage period
- 2023-06-01 to present
- Deductible
- $2,189.57 of $2,500.0088%
- Out-of-pocket maximum
- $607.66 of $10,000.006%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 2571625872
- Network
- In network
- Rendering NPI
- 2571625872
- Location
- Dallas, TX · TIN 43-0454627
- Authorisation / referral
- none / REF398270
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 | 71046 rev 0320 | Chest X-ray, two views | 59 | 1 | 1 | $141.00 | $77.55 | — | — | Review |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | 59 | 1 | 1 | $477.00 | $262.35 | — | — | Review |
| Totals | $618.00 | $339.90 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-512845
- 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-023899 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-10: NAVIGATE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 20 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 Desert Diagnostic Imaging (2571625872). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Desert Diagnostic Imaging2026-09-10 12:38
Patient seen for unspecified abdominal pain. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-09-30 06:20
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Itemized billitemized_PA-512845.pdf6 pages
Itemised statement totalling $618.00 across 2 lines.
- Medical recordrecords_PA-512845.pdf11 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.