CLM-2026-012625
Lakeside Imaging Center, Radiology. Service 2026-05-15 at outpatient hospital (POS 22). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Michelle Schultz
- Member ID
- none on golden record
- Date of birth
- 1971-05-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415792
- Relationship
- Child
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-5103
- Coverage period
- 2022-03-01 to 2026-03-19
- Deductible
- $349.64 of $500.0070%
- Out-of-pocket maximum
- $211.81 of $1,000.0021%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4829743648
- Network
- In network
- Rendering NPI
- 4829743648
- Location
- Minneapolis, MN · TIN 87-3632325
- Authorisation / referral
- PA2025161430 / REF443890
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 | $2,240.00 | $1,232.00 | — | — | DeniedCO27 |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $1,952.00 | $1,073.60 | — | — | DeniedCO27 |
| Totals | $4,192.00 | $2,305.60 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-629402
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001229; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-05-15 is after coverage terminated on 2026-03-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025161430 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (4829743648). | |
| 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: Lakeside Imaging Center2026-05-15 18:09
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-07 03:27
Attachments
Documents received with the claim
- Prior auth letterPA2025161430_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-05-15 to 2026-08-13.
- Itemized billitemized_PA-629402.pdf9 pages
Itemised statement totalling $4192.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-001229; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-05-15 is after coverage terminated on 2026-03-19.
Other claims for this member
Same resolved identity
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
Service after coverage termination.