CLM-2026-011755
Evergreen Diagnostic Imaging, Radiology. Service 2026-07-24 at outpatient hospital (POS 22). Received 2026-08-10.
Member
Resolved through the identity graph
- Member
- Hiroshi Martinez
- Member ID
- UHC-21659-34
- Date of birth
- 1993-08-16
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427045
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6003
- Coverage period
- 2024-08-01 to 2026-08-26
- Deductible
- $140.49 of $1,000.0014%
- Out-of-pocket maximum
- $1,570.95 of $4,000.0039%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 4970897466
- Network
- In network
- Rendering NPI
- 4970897466
- Location
- Charlotte, NC · TIN 79-7771528
- Authorisation / referral
- none / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $115.00 | $63.25 | $63.25 | $0.00 | Paid |
| Totals | $115.00 | $63.25 | $63.25 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-728363
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029992 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-24: CORE-HMO (HMO), effective 2024-08-01, terms 2026-08-26. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (4970897466). | |
| 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 Imaging2026-07-24 15:22
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-728363.pdf3 pages
Itemised statement totalling $115.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010776 | 2026-09-11 | Valley Bone and Joint Center | $51,314.00 | Denied |
| CLM-2026-023130 | 2026-08-07 | Meadow Heart Institute | $1,218.00 | Denied |
| CLM-2026-028818 | 2026-04-02 | Sunrise Clinical Laboratories | $51.00 | Approved |
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.