CLM-2026-010638
Valley Imaging Center, Radiology. Service 2026-02-16 at outpatient hospital (POS 22). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Judith Dunn
- Member ID
- UHC-01652-57
- Date of birth
- 1974-06-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412867
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9810
- Coverage period
- 2021-08-01 to present
- Deductible
- $1,053.28 of $3,500.0030%
- Out-of-pocket maximum
- $987.14 of $10,500.009%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 5964910181
- Network
- In network
- Rendering NPI
- 5964910181
- Location
- Austin, TX · TIN 60-0192260
- Authorisation / referral
- PA2025750585 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $395.00 | $217.25 | $217.25 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $1,939.00 | $1,066.45 | $1,066.45 | $0.00 | Paid |
| Totals | $2,334.00 | $1,283.70 | $1,283.70 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-771561
- 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-015038 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-16: OPTIONS-PPO (PPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025750585 on file for 70553. | |
| Provider network | Pass | In-network provider Valley Imaging Center (5964910181). | |
| 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 Center2026-02-16 12:19
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025750585_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-02-16 to 2026-05-17.
- Itemized billitemized_PA-771561.pdf5 pages
Itemised statement totalling $2334.00 across 2 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
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.