CLM-2026-013494
Desert Diagnostic Imaging, Radiology. Service 2026-06-07 at outpatient hospital (POS 22). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Michelle Clark
- Member ID
- UHC-76779-12
- Date of birth
- 1987-06-28
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-421320
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9549
- Coverage period
- 2023-04-01 to present
- Deductible
- $931.77 of $2,500.0037%
- Out-of-pocket maximum
- $1,678.17 of $10,000.0017%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 2571625872
- Network
- In network
- Rendering NPI
- 2571625872
- Location
- Dallas, TX · TIN 43-0454627
- Authorisation / referral
- PA2026884438 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $480.00 | $264.00 | $264.00 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $380.00 | $209.00 | $209.00 | $0.00 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 2 | $3,231.00 | $1,777.05 | $1,163.41 | $613.64 | Paid |
| Totals | $4,091.00 | $2,250.05 | $1,636.41 | $613.64 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-604978
- 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-018282 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-07: NULL (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026884438 on file for 70553. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (2571625872). | |
| 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: Desert Diagnostic Imaging2026-06-07 11:14
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026884438_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-06-07 to 2026-09-05.
- Itemized billitemized_PA-604978.pdf2 pages
Itemised statement totalling $4091.00 across 3 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-2026-007939 | 2026-06-04 | Sunrise Dermatology Clinic | $406.00 | Needs review |
| CLM-2026-007938 | 2026-06-04 | Sunrise Dermatology Clinic | $406.00 | Approved |
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.