CLM-2026-014934
Desert Imaging Center, Radiology. Service 2026-08-08 at outpatient hospital (POS 22). Received 2026-09-22.
Member
Resolved through the identity graph
- Member
- Harold Morales
- Member ID
- UHC-68587-26
- Date of birth
- 1949-11-28
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-421801
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9330
- Coverage period
- 2024-04-01 to present
- Deductible
- $581.32 of $2,500.0023%
- Out-of-pocket maximum
- $347.94 of $7,500.005%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7235030955
- Network
- In network
- Rendering NPI
- 7235030955
- Location
- San Diego, CA · TIN 44-8505123
- Authorisation / referral
- PA2025644921 / 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 | $202.00 | $111.10 | $111.10 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $398.00 | $218.90 | $218.90 | $0.00 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,574.00 | $1,965.70 | $1,664.08 | $301.62 | Paid |
| Totals | $4,174.00 | $2,295.70 | $1,994.08 | $301.62 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-808401
- 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-022771 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-08: OPTIONS-PPO (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025644921 on file for 70553. | |
| Provider network | Pass | In-network provider Desert Imaging Center (7235030955). | |
| 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 Imaging Center2026-08-08 11:28
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025644921_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-08-08 to 2026-11-06.
- Itemized billitemized_PA-808401.pdf8 pages
Itemised statement totalling $4174.00 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
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.