CLM-2026-011892
Desert Diagnostic Imaging, Radiology. Service 2026-04-12 at outpatient hospital (POS 22). Received 2026-04-27.
Member
Resolved through the identity graph
- Member
- Dennis Hart
- Member ID
- UHC-52556-86
- Date of birth
- 1994-12-15
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-407896
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5396
- Coverage period
- 2021-01-01 to present
- Deductible
- $3,018.39 of $3,500.0086%
- Out-of-pocket maximum
- $437.01 of $7,000.006%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3515366425
- Network
- In network
- Rendering NPI
- 3515366425
- Location
- Phoenix, AZ · TIN 68-2801174
- Authorisation / referral
- PA2025803787 / 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 | $3,205.00 | $1,762.75 | $865.95 | $896.80 | Paid |
| Totals | $3,205.00 | $1,762.75 | $865.95 | $896.80 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-537556
- 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-028046 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-12: SELECT-EPO (EPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025803787 on file for 70553. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (3515366425). | |
| 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: Desert Diagnostic Imaging2026-04-12 13:30
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025803787_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-12 to 2026-07-11.
- Itemized billitemized_PA-537556.pdf9 pages
Itemised statement totalling $3205.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 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.