CLM-2026-015633
Canyon Diagnostic Imaging, Radiology. Service 2026-08-05 at outpatient hospital (POS 22). Received 2026-09-09.
Member
Resolved through the identity graph
- Member
- Eugene Reyes
- Member ID
- UHC-92197-11
- Date of birth
- 1966-05-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430719
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7486
- Coverage period
- 2022-08-01 to present
- Deductible
- $810.89 of $1,000.0081%
- Out-of-pocket maximum
- $386.31 of $2,000.0019%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6871661313
- Network
- In network
- Rendering NPI
- 6871661313
- Location
- Tampa, FL · TIN 87-4174394
- Authorisation / referral
- none / REF472825
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 | $3,080.00 | $1,694.00 | — | — | DeniedCO197 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $2,487.00 | $1,367.85 | — | — | DeniedCO197 |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $637.00 | $350.35 | — | — | DeniedCO197 |
| Totals | $6,204.00 | $3,412.20 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-731459
- 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-033017 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-05: CORE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553, 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (6871661313). | |
| 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: Canyon Diagnostic Imaging2026-08-05 12:37
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-09 00:27
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-09 16:55
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-731459.pdf9 pages
Itemised statement totalling $6204.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 70553, 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.