CLM-2026-012276
Mesa Imaging Center, Radiology. Service 2025-11-29 at outpatient hospital (POS 22). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Aaron Johnson
- Member ID
- UHC-30422-67
- Date of birth
- 1978-11-04
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-423688
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3973
- Coverage period
- 2022-06-01 to present
- Deductible
- $526.57 of $1,500.0035%
- Out-of-pocket maximum
- $1,035.64 of $3,000.0035%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 6656135814
- Network
- Out of network
- Rendering NPI
- 6656135814
- Location
- Minneapolis, MN · TIN 75-3868074
- Authorisation / referral
- none / REF948413
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 | $167.00 | $75.15 | — | — | DeniedCO204 |
| Totals | $167.00 | $75.15 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-281012
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002612 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-11-29: NAVIGATE-HMO (HMO), effective 2022-06-01. | |
| Timely filing | Pass | Received 41 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 | Fail | CO204 | Billing provider 6656135814 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Mesa Imaging Center2025-11-29 09:31
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-09 04:59
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-09 12:44
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-281012.pdf9 pages
Itemised statement totalling $167.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 6656135814 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005225 | 2026-08-21 | Meadow Heart Institute | $5,475.00 | Denied |
| CLM-2026-027758 | 2025-12-28 | Northgate Medical Group | $208.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.