CLM-2026-014487
Evergreen Diagnostic Imaging, Radiology. Service 2026-02-25 at outpatient hospital (POS 22). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- Raymond Kim
- Member ID
- UHC-89856-22
- Date of birth
- 2002-05-10
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-415055
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8547
- Coverage period
- 2023-11-01 to present
- Deductible
- $587.50 of $2,500.0024%
- Out-of-pocket maximum
- $3,114.82 of $10,000.0031%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 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
- PA2026865249 / REF389617
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 | $2,249.00 | $1,236.95 | $1,236.95 | $0.00 | Paid |
| Totals | $2,249.00 | $1,236.95 | $1,236.95 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R07.9 Chest pain, unspecified
- 3. R51.9 Headache, unspecified
- Patient account
- PA-847902
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010006 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-25: NAVIGATE-HMO (HMO), effective 2023-11-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026865249 on file for 74177. | |
| 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 Imaging2026-02-25 12:07
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026865249_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-02-25 to 2026-05-26.
- Itemized billitemized_PA-847902.pdf7 pages
Itemised statement totalling $2249.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031550 | 2026-02-20 | Northgate Bone and Joint Center | $202.00 | Denied |
| CLM-2026-014488 | 2026-02-25 | Canyon Diagnostic Imaging | $2,249.00 | Needs review |
| CLM-2026-027362 | 2026-03-04 | Meadow Imaging Center | $727.00 | Approved |
| CLM-2026-013971 | 2026-01-14 | Unity Dermatology Clinic | $213.00 | 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.