CLM-2026-013354
Evergreen Diagnostic Imaging, Radiology. Service 2025-12-31 at outpatient hospital (POS 22). Received 2026-01-24.
Member
Resolved through the identity graph
- Member
- Brandon Rivera
- Member ID
- UHC-19255-33
- Date of birth
- 1991-04-07
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-415309
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group N/A
- Coverage period
- 2025-08-01 to present
- Deductible
- $284.31 of $2,500.0011%
- Out-of-pocket maximum
- $506.10 of $5,000.0010%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 7098075170
- Network
- In network
- Rendering NPI
- 7098075170
- Location
- Atlanta, GA · TIN 75-1814880
- Authorisation / referral
- none / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $149.00 | $81.95 | $81.95 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $437.00 | $240.35 | $240.35 | $0.00 | Paid |
| Totals | $586.00 | $322.30 | $322.30 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-772146
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004545 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-31: OPTIONS-PPO (PPO), effective 2025-08-01. | |
| 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 Evergreen Diagnostic Imaging (7098075170). | |
| 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: Evergreen Diagnostic Imaging2025-12-31 12:14
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-772146.pdf8 pages
Itemised statement totalling $586.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001341 | 2026-08-20 | Heritage Rehabilitation Center | $368.00 | 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.