CLM-2026-010035
Valley Imaging Center, Radiology. Service 2026-08-13 at outpatient hospital (POS 22). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Kathy Watkins
- Member ID
- UHC-19886-37
- Date of birth
- 1972-05-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-415395
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7677
- Coverage period
- 2024-03-01 to present
- Deductible
- $1,775.45 of $3,500.0051%
- Out-of-pocket maximum
- $1,882.42 of $7,000.0027%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7696270280
- Network
- In network
- Rendering NPI
- 7696270280
- Location
- Scottsdale, AZ · TIN 61-0618370
- Authorisation / referral
- PA2025321168 / 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 | $2,751.00 | $1,513.05 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $127.00 | $69.85 | — | — | Review |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 1 | $1,562.00 | $859.10 | — | — | Review |
| Totals | $4,440.00 | $2,442.00 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-377708
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028240 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-13: N/A (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 51 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-010034; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | Authorisation PA2025321168 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Valley Imaging Center (7696270280). | |
| 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: Valley Imaging Center2026-08-13 17:53
Follow-up for headache, unspecified. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-10-03 06:45
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-03 15:31
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025321168_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-13 to 2026-11-11.
- Itemized billitemized_PA-377708.pdf4 pages
Itemised statement totalling $4440.00 across 3 lines.
- Corrected claimcorrected_CLM-2026-010034.pdf1 page
Provider cover letter requesting replacement of CLM-2026-010034.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-010034; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010034 | 2026-08-13 | Valley Imaging Center | $4,440.00 | Approved |
| CLM-2026-000824 | 2026-05-01 | Heritage Primary Care Associates | $611.00 | 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
Replacement claim supersedes the original.