CLM-2026-009752
Canyon Diagnostic Imaging, Radiology. Service 2026-07-27 at outpatient hospital (POS 22). Received 2026-08-29.
Member
Resolved through the identity graph
- Member
- Patricia Payne
- Member ID
- UHC-57067-49
- Date of birth
- 2003-11-14
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415816
- Relationship
- Child, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1583
- Coverage period
- 2024-10-01 to present
- Deductible
- $268.18 of $1,500.0018%
- Out-of-pocket maximum
- $2,218.77 of $4,500.0049%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1352145704
- Network
- In network
- Rendering NPI
- 1352145704
- Location
- Atlanta, GA · TIN 24-1782323
- Authorisation / referral
- PA2025395181 / 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 | $234.00 | $128.70 | $128.70 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,463.00 | $804.65 | $804.65 | $0.00 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,476.00 | $1,911.80 | $782.47 | $1,129.33 | Paid |
| Totals | $5,173.00 | $2,845.15 | $1,715.82 | $1,129.33 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-602168
- 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-005332 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-27: OPTIONS-PPO (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025395181 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (1352145704). | |
| 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 Imaging2026-07-27 12:39
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Prior auth letterPA2025395181_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-07-27 to 2026-10-25.
- Itemized billitemized_PA-602168.pdf5 pages
Itemised statement totalling $5173.00 across 3 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-2026-026189 | 2026-08-18 | Harbor Reference Lab | $44.00 | Approved |
| CLM-2026-025293 | 2025-10-11 | Heritage Imaging Center | $635.00 | Denied |
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.