CLM-2026-009668
Summit Diagnostic Imaging, Radiology. Service 2026-03-13 at outpatient hospital (POS 22). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Elijah Lawrence
- Member ID
- none on golden record
- Date of birth
- 1960-10-13
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406426
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-9378
- Coverage period
- 2025-01-01 to present
- Deductible
- $688.58 of $1,000.0069%
- Out-of-pocket maximum
- $1,664.97 of $4,000.0042%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8935049519
- Network
- In network
- Rendering NPI
- 8935049519
- Location
- Los Angeles, CA · TIN 90-8085018
- Authorisation / referral
- none / REF169841
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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,547.00 | $1,400.85 | — | — | DeniedCO197 |
| Totals | $2,547.00 | $1,400.85 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-422436
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021588 (provisional, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-03-13: NAVIGATE-HMO (HMO), effective 2025-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Summit Diagnostic Imaging (8935049519). | |
| 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: Summit Diagnostic Imaging2026-03-13 12:40
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-03-23 05:04
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-23 14:32
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-422436.pdf3 pages
Itemised statement totalling $2547.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Active on 2026-03-13: NAVIGATE-HMO (HMO), effective 2025-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. Prior authorisation: 74177 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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
Precertification required and absent.