CLM-2026-012200
Riverside Imaging Center, Radiology. Service 2026-08-21 at outpatient hospital (POS 22). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Lauren Lynch
- Member ID
- UHC-13897-33
- Date of birth
- 1993-07-24
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-412378
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4211
- Coverage period
- 2024-02-01 to present
- Deductible
- $293.20 of $1,000.0029%
- Out-of-pocket maximum
- $442.14 of $4,000.0011%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 14 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
- PA2025223845 / 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 | $1,786.00 | $982.30 | $734.35 | $247.95 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $177.00 | $97.35 | $9.74 | $87.61 | Paid |
| Totals | $1,963.00 | $1,079.65 | $744.09 | $335.56 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-911092
- 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-039674 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-21: OPTIONS-PPO (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025223845 on file for 74177. | |
| 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 Center2026-08-21 17:42
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025223845_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-21 to 2026-11-19.
- Itemized billitemized_PA-911092.pdf9 pages
Itemised statement totalling $1963.00 across 2 lines.
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-2026-018920 | 2026-08-23 | Valley Cardiovascular Associates | $8,424.00 | Needs review |
| CLM-2026-007618 | 2026-07-14 | Desert Internal Medicine Associates | $246.00 | Approved |
| CLM-2026-001483 | 2026-06-16 | Heritage Medical Group | $769.00 | Needs review |
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.