CLM-2026-009109
Desert Diagnostic Imaging, Radiology. Service 2026-01-02 at outpatient hospital (POS 22). Received 2026-01-25.
Member
Resolved through the identity graph
- Member
- Dylan Hansen
- Member ID
- UHC-01817-18
- Date of birth
- 1994-07-05
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-421524
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9127
- Coverage period
- 2024-04-01 to 2026-06-08
- Deductible
- $604.65 of $2,500.0024%
- Out-of-pocket maximum
- $906.03 of $5,000.0018%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 3 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
- PA2026564667 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $162.00 | $89.10 | $89.10 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $548.00 | $301.40 | $301.40 | $0.00 | Paid |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,596.00 | $1,427.80 | $1,427.80 | $0.00 | Paid |
| Totals | $3,306.00 | $1,818.30 | $1,818.30 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R07.9 Chest pain, unspecified
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-333987
- 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-007532 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-02: CHOICE-PLUS-PPO (PPO), effective 2024-04-01, terms 2026-06-08. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026564667 on file for 74177. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (2571625872). | |
| 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: Desert Diagnostic Imaging2026-01-02 14:55
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026564667_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-01-02 to 2026-04-02.
- Itemized billitemized_PA-333987.pdf7 pages
Itemised statement totalling $3306.00 across 3 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
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.