CLM-2026-012094
Canyon Diagnostic Imaging, Radiology. Service 2026-08-13 at outpatient hospital (POS 22). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Jean Scott
- Member ID
- UHC-25460-52
- Date of birth
- 1974-06-25
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-420725
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5256
- Coverage period
- 2021-04-01 to present
- Deductible
- $334.81 of $1,500.0022%
- Out-of-pocket maximum
- $935.69 of $6,000.0016%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 12 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
- none / REF343482
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 | $293.00 | $161.15 | $161.15 | $0.00 | Paid |
| Totals | $293.00 | $161.15 | $161.15 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-605377
- 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-017917 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-13: NAVIGATE-HMO (HMO), effective 2021-04-01. | |
| Timely filing | Pass | Received 24 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 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 Imaging2026-08-13 17:29
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-605377.pdf3 pages
Itemised statement totalling $293.00 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
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.