CLM-2026-009606
Riverside Imaging Center, Radiology. Service 2026-02-13 at outpatient hospital (POS 22). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Rachel Coleman
- Member ID
- none on golden record
- Date of birth
- 1971-12-27
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-423220
- Relationship
- Child
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-2465
- Coverage period
- 2022-10-01 to present
- Deductible
- $673.80 of $3,500.0019%
- Out-of-pocket maximum
- $2,838.27 of $7,000.0041%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7427092680
- Network
- In network
- Rendering NPI
- 7427092680
- Location
- Mesa, AZ · TIN 33-8428995
- Authorisation / referral
- PA2026664406 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,327.00 | $1,829.85 | — | — | PendedIDQ |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,426.00 | $784.30 | — | — | PendedIDQ |
| Totals | $4,753.00 | $2,614.15 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. R51.9 Headache, unspecified
- Patient account
- PA-581911
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000243; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-02-13: MEDICARE-ADV-A (MA), effective 2022-10-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026664406 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Riverside Imaging Center (7427092680). | |
| 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: Riverside Imaging Center2026-02-13 12:39
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026664406_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-02-13 to 2026-05-14.
- Itemized billitemized_PA-581911.pdf9 pages
Itemised statement totalling $4753.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000243; payment withheld until the identity is confirmed. Eligibility: Active on 2026-02-13: MEDICARE-ADV-A (MA), effective 2022-10-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.