CLM-2026-010067
Evergreen Diagnostic Imaging, Radiology. Service 2026-08-11 at outpatient hospital (POS 22). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- Fatima Sandoval
- Member ID
- UHC-28392-80
- Date of birth
- 1987-09-14
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-410259
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group -
- Coverage period
- 2024-09-01 to 2026-07-02
- Deductible
- $315.87 of $500.0063%
- Out-of-pocket maximum
- $456.22 of $1,000.0046%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 7098075170
- Network
- In network
- Rendering NPI
- 7098075170
- Location
- Atlanta, GA · TIN 75-1814880
- Authorisation / referral
- PA2026721297 / REF397285
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 | $2,880.00 | $1,584.00 | — | — | DeniedCO27 |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $437.00 | $240.35 | — | — | DeniedCO27 |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $201.00 | $110.55 | — | — | DeniedCO27 |
| Totals | $3,518.00 | $1,934.90 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-913276
- 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-040115 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-11 is after coverage terminated on 2026-07-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026721297 on file for 70553. | |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (7098075170). | |
| 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: Evergreen Diagnostic Imaging2026-08-11 10:22
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-08-23 03:09
Attachments
Documents received with the claim
- Prior auth letterPA2026721297_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-11 to 2026-11-09.
- Itemized billitemized_PA-913276.pdf6 pages
Itemised statement totalling $3518.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-11 is after coverage terminated on 2026-07-02.
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
Service after coverage termination.