CLM-2026-010907
Canyon Diagnostic Imaging, Radiology. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-01-14.
Member
Resolved through the identity graph
- Member
- Philip Whtie
- Member ID
- UHC-56598-37
- Date of birth
- 1992-10-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-425618
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9289
- Coverage period
- 2023-08-01 to present
- Deductible
- $1,368.80 of $2,500.0055%
- Out-of-pocket maximum
- $2,798.90 of $10,000.0028%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6871661313
- Network
- In network
- Rendering NPI
- 6871661313
- Location
- Tampa, FL · TIN 87-4174394
- Authorisation / referral
- PA2026918300 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,785.00 | $981.75 | $981.75 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $351.00 | $193.05 | $158.17 | $34.88 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $613.00 | $337.15 | $67.43 | $269.72 | Paid |
| Totals | $2,749.00 | $1,511.95 | $1,207.35 | $304.60 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-832401
- 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-004316 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-07: CHOICE-PLUS-PPO (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026918300 on file for 74177. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (6871661313). | |
| 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: Canyon Diagnostic Imaging2026-01-07 16:36
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026918300_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-01-07 to 2026-04-07.
- Itemized billitemized_PA-832401.pdf3 pages
Itemised statement totalling $2749.00 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.