CLM-2026-014185
Northgate Imaging Center, Radiology. Service 2026-06-18 at outpatient hospital (POS 22). Received 2026-06-27.
Member
Resolved through the identity graph
- Member
- Douglas Fox
- Member ID
- UHC-38814-45
- Date of birth
- 1960-12-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-416126
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4871
- Coverage period
- 2023-03-01 to present
- Deductible
- $845.53 of $2,500.0034%
- Out-of-pocket maximum
- $920.54 of $10,000.009%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3050464585
- Network
- Out of network
- Rendering NPI
- 3050464585
- Location
- San Diego, CA · TIN 61-2250278
- 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $405.00 | $182.25 | $182.25 | $0.00 | Paid |
| Totals | $405.00 | $182.25 | $182.25 | $0.00 | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-820918
- 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-030489 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-18: OPTIONS-PPO (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 9 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Northgate Imaging Center2026-06-18 18:24
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-820918.pdf7 pages
Itemised statement totalling $405.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031654 | 2026-07-25 | Unity Reference Lab | $109.00 | 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.