CLM-2026-010397
Summit Diagnostic Imaging, Radiology. Service 2025-09-14 at outpatient hospital (POS 22). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- Jack Watson
- Member ID
- UHC-54078-08
- Date of birth
- 1988-08-25
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-413065
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2900
- Coverage period
- 2025-09-01 to present
- Deductible
- $584.26 of $3,500.0017%
- Out-of-pocket maximum
- $3,490.97 of $10,500.0033%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 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
- PA2025196558 / 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 | $2,411.00 | $1,326.05 | — | — | DeniedCO29 |
| Totals | $2,411.00 | $1,326.05 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-176466
- 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-021920 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-09-14: MEDICARE-ADV-A (MA), effective 2025-09-01. | |
| Timely filing | Fail | CO29 | Received 202 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025196558 on file for 70553. | |
| 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 Imaging2025-09-14 14:52
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-04-04 00:08
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2025196558_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-09-14 to 2025-12-13.
- Itemized billitemized_PA-176466.pdf3 pages
Itemised statement totalling $2411.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 202 days after the last date of service (limit 90).
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
Received after the timely-filing limit.