CLM-2026-014643
Mesa Imaging Center, Radiology. Service 2026-10-06 at outpatient hospital (POS 22). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Wayne Williamson
- Member ID
- UHC-45751-58
- Date of birth
- 1983-05-16
- Identity
- Verified3 records, confidence 0.86
- Claim record
- CLMCLM-427503
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7531
- Coverage period
- 2024-05-01 to present
- Deductible
- $186.14 of $500.0037%
- Out-of-pocket maximum
- $542.22 of $1,500.0036%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 6656135814
- Network
- Out of network
- Rendering NPI
- 6656135814
- Location
- Minneapolis, MN · TIN 75-3868074
- 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,403.00 | $1,081.35 | — | — | DeniedCO197 |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $412.00 | $185.40 | — | — | DeniedCO197 |
| Totals | $2,815.00 | $1,266.75 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-533984
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023507 (verified, link confidence 0.86). | |
| Eligibility | Pass | Active on 2026-10-06: NULL (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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: Mesa Imaging Center2026-10-06 14:45
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-10-10 04:59
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-10 16:51
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-533984.pdf6 pages
Itemised statement totalling $2815.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 70553 require precertification; no authorisation number on the claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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
Precertification required and absent.