CLM-2026-015114
Summit Imaging Center, Radiology. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-02-10.
Member
Resolved through the identity graph
- Member
- Susan Ray
- Member ID
- UHC-29128-75
- Date of birth
- 1945-09-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-403902
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6655
- Coverage period
- 2024-08-01 to present
- Deductible
- $16.83 of $1,000.002%
- Out-of-pocket maximum
- $1,292.78 of $4,000.0032%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4562878908
- Network
- In network
- Rendering NPI
- 4562878908
- Location
- Minneapolis, MN · TIN 57-8653616
- Authorisation / referral
- none / REF830181
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 | $1,541.00 | $847.55 | — | — | DeniedCO197 |
| Totals | $1,541.00 | $847.55 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-112422
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012032 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-07: NAVIGATE-HMO (HMO), effective 2024-08-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Summit Imaging Center (4562878908). | |
| 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: Summit Imaging Center2026-01-07 17:58
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-10 06:34
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-10 09:05
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-112422.pdf8 pages
Itemised statement totalling $1541.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 74177 require precertification; no authorisation number on the claim.
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.