CLM-2026-009163
Desert Imaging Center, Radiology. Service 2026-02-19 at outpatient hospital (POS 22). Received 2026-03-27.
Member
Resolved through the identity graph
- Member
- Omar Li
- Member ID
- UHC-33271-88
- Date of birth
- 1952-06-27
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-426920
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0949
- Coverage period
- 2023-03-01 to present
- Deductible
- $930.37 of $2,500.0037%
- Out-of-pocket maximum
- $2,726.20 of $10,000.0027%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7235030955
- Network
- In network
- Rendering NPI
- 7235030955
- Location
- San Diego, CA · TIN 44-8505123
- 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 | $311.00 | $171.05 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1 | $162.00 | $89.10 | — | — | Review |
| Totals | $473.00 | $260.15 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-502792
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022335 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-19: CORE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 36 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 Imaging Center (7235030955). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for chest pain, unspecified. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Imaging Center2026-02-19 14:35
Patient seen for chest pain, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-27 02:28
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-27 17:52
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-502792.pdf3 pages
Itemised statement totalling $473.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for chest pain, unspecified. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010239 | 2026-02-20 | Meadow Family Practice | $507.00 | Needs review |
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
Development letter outstanding.