CLM-2026-009246
Canyon Diagnostic Imaging, Radiology. Service 2025-12-15 at outpatient hospital (POS 22). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Ana Fernandez
- Member ID
- UHC-14297-96
- Date of birth
- 1968-02-05
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-425323
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-3011
- Coverage period
- 2021-05-01 to present
- Deductible
- $301.72 of $500.0060%
- Out-of-pocket maximum
- $973.20 of $2,000.0049%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8055565153
- Network
- In network
- Rendering NPI
- 8055565153
- Location
- Atlanta, GA · TIN 44-7708549
- 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 | $412.00 | $226.60 | $203.94 | $22.66 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $438.00 | $240.90 | $48.18 | $192.72 | Paid |
| Totals | $850.00 | $467.50 | $252.12 | $215.38 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-773362
- 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-001949 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-15: UNKNOWN (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 23 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 Canyon Diagnostic Imaging (8055565153). | |
| 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: Canyon Diagnostic Imaging2025-12-15 09:44
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-773362.pdf2 pages
Itemised statement totalling $850.00 across 2 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034510 | 2025-11-29 | Unity Primary Care Associates | $52.00 | 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.