CLM-2026-009766
Heritage Imaging Center, Radiology. Service 2026-08-28 at outpatient hospital (POS 22). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Billy Brown
- Member ID
- UHC-09978-13
- Date of birth
- 1977-12-04
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-423859
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0136
- Coverage period
- 2024-01-01 to present
- Deductible
- $352.53 of $500.0071%
- Out-of-pocket maximum
- $303.47 of $1,000.0030%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4466693437
- Network
- In network
- Rendering NPI
- 4466693437
- Location
- Atlanta, GA · TIN 36-7680074
- Authorisation / referral
- PA2026891350 / 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 | $3,236.00 | $1,779.80 | — | — | Review |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $356.00 | $195.80 | — | — | Review |
| Totals | $3,592.00 | $1,975.60 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R51.9 Headache, unspecified
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-216726
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012657 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-08-28: OPTIONS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026891350 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Imaging Center (4466693437). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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: Heritage Imaging Center2026-08-28 12:05
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Prior auth letterPA2026891350_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-28 to 2026-11-26.
- Itemized billitemized_PA-216726.pdf6 pages
Itemised statement totalling $3592.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009767 | 2026-08-28 | Cornerstone Imaging Center | $3,592.00 | Needs review |
| CLM-2026-019918 | 2026-01-31 | Mesa Dermatology Clinic | $544.00 | Approved |
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.