CLM-2026-008906
Evergreen Diagnostic Imaging, Radiology. Service 2026-04-29 at outpatient hospital (POS 22). Received 2026-05-12.
Member
Resolved through the identity graph
- Member
- Rachel Hughes
- Member ID
- UHC-06997-78
- Date of birth
- 1969-06-06
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-403374
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1331
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,224.05 of $2,500.0049%
- Out-of-pocket maximum
- $715.07 of $5,000.0014%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 4970897466
- Network
- In network
- Rendering NPI
- 4970897466
- Location
- Charlotte, NC · TIN 79-7771528
- 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $260.00 | $143.00 | $143.00 | $0.00 | Paid |
| Totals | $260.00 | $143.00 | $143.00 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-835572
- 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-003538 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-29: MEDICARE-ADV-B (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 13 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 Evergreen Diagnostic Imaging (4970897466). | |
| 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 Imaging2026-04-29 11:24
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-835572.pdf7 pages
Itemised statement totalling $260.00 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-2026-020736 | 2026-04-24 | Pinecrest Bone and Joint Center | $266.00 | 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.