CLM-2026-009513
Harbor Imaging Center, Radiology. Service 2025-07-20 at outpatient hospital (POS 22). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Sofia Walker
- Member ID
- UHC-07458-97
- Date of birth
- 1997-10-01
- Identity
- Verified5 records, confidence 0.86
- Claim record
- CLMCLM-424139
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9026
- Coverage period
- 2023-10-01 to 2026-08-12
- Deductible
- $277.48 of $500.0055%
- Out-of-pocket maximum
- $406.78 of $2,000.0020%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3423421452
- Network
- In network
- Rendering NPI
- 3423421452
- Location
- Denver, CO · TIN 47-9293451
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $121.00 | $66.55 | — | — | DeniedCO29 |
| Totals | $121.00 | $66.55 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-511488
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002935 (verified, link confidence 0.86). | |
| Eligibility | Pass | Active on 2025-07-20: MEDICARE-ADV-A (MA), effective 2023-10-01, terms 2026-08-12. | |
| Timely filing | Fail | CO29 | Received 174 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Imaging Center (3423421452). | |
| 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: Harbor Imaging Center2025-07-20 12:05
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-10 03:23
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-511488.pdf4 pages
Itemised statement totalling $121.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 174 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014153 | 2026-08-16 | Summit Primary Care Associates | $507.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.