CLM-2026-012703
Valley Imaging Center, Radiology. Service 2026-03-06 at outpatient hospital (POS 22). Received 2026-03-15.
Member
Resolved through the identity graph
- Member
- Diego Lane
- Member ID
- UHC-36112-57
- Date of birth
- 1943-06-06
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-415893
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-6461
- Coverage period
- 2024-03-01 to 2026-01-20
- Deductible
- $362.85 of $2,500.0015%
- Out-of-pocket maximum
- $809.48 of $10,000.008%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 5964910181
- Network
- In network
- Rendering NPI
- 5964910181
- Location
- Austin, TX · TIN 60-0192260
- Authorisation / referral
- PA2025462360 / 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 | $2,441.00 | $1,342.55 | — | — | DeniedCO27 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,015.00 | $1,108.25 | — | — | DeniedCO27 |
| Totals | $4,456.00 | $2,450.80 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-543037
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005983 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-06 is after coverage terminated on 2026-01-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025462360 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Valley Imaging Center (5964910181). | |
| 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: Valley Imaging Center2026-03-06 17:40
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-15 03:17
Attachments
Documents received with the claim
- Prior auth letterPA2025462360_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-03-06 to 2026-06-04.
- Itemized billitemized_PA-543037.pdf3 pages
Itemised statement totalling $4456.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-06 is after coverage terminated on 2026-01-20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026755 | 2025-12-24 | Desert Primary Care Associates | $24.00 | Needs review |
| CLM-2026-026754 | 2025-12-24 | Desert Primary Care Associates | $24.00 | 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
Service after coverage termination.