CLM-2026-010696
Riverside Imaging Center, Radiology. Service 2026-01-27 at outpatient hospital (POS 22). Received 2026-03-12.
Member
Resolved through the identity graph
- Member
- Marcus Jones
- Member ID
- UHC-16298-63
- Date of birth
- 1952-02-04
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-407707
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9962
- Coverage period
- 2023-04-01 to present
- Deductible
- $1,986.81 of $2,500.0079%
- Out-of-pocket maximum
- $732.50 of $5,000.0015%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7427092680
- Network
- In network
- Rendering NPI
- 7427092680
- Location
- Mesa, AZ · TIN 33-8428995
- Authorisation / referral
- PA2026212862 / 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $299.00 | $164.45 | $164.45 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,071.00 | $1,139.05 | $506.80 | $632.25 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $452.00 | $248.60 | $49.72 | $198.88 | Paid |
| Totals | $2,822.00 | $1,552.10 | $720.97 | $831.13 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-632335
- 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-019175 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-27: NAVIGATE-HMO (HMO), effective 2023-04-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026212862 on file for 70553. | |
| Provider network | Pass | In-network provider Riverside Imaging Center (7427092680). | |
| 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: Riverside Imaging Center2026-01-27 10:46
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026212862_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-01-27 to 2026-04-27.
- Itemized billitemized_PA-632335.pdf4 pages
Itemised statement totalling $2822.00 across 3 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.