CLM-2026-008696
Riverside Diagnostic Imaging, Radiology. Service 2026-10-02 at outpatient hospital (POS 22). Received 2026-10-14.
Member
Resolved through the identity graph
- Member
- Joan Duncan
- Member ID
- UHC-84887-28
- Date of birth
- 1993-05-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424010
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6114
- Coverage period
- 2023-08-01 to present
- Deductible
- $464.18 of $1,500.0031%
- Out-of-pocket maximum
- $520.17 of $3,000.0017%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6802768252
- Network
- In network
- Rendering NPI
- 6802768252
- Location
- Scottsdale, AZ · TIN 85-0998777
- Authorisation / referral
- none / REF913351
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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $373.00 | $205.15 | $205.15 | $0.00 | Paid |
| Totals | $373.00 | $205.15 | $205.15 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-681044
- 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-042472 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-02: CORE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 12 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 Riverside Diagnostic Imaging (6802768252). | |
| 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: Riverside Diagnostic Imaging2026-10-02 16:02
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-681044.pdf5 pages
Itemised statement totalling $373.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.