CLM-2026-015919
Northgate Imaging Center, Radiology. Service 2025-12-15 at outpatient hospital (POS 22). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Christine Cunningham
- Member ID
- UHC-36095-33
- Date of birth
- 1980-12-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-423196
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9254
- Coverage period
- 2024-07-01 to present
- Deductible
- $253.53 of $500.0051%
- Out-of-pocket maximum
- $290.39 of $1,000.0029%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3050464585
- Network
- Out of network
- Rendering NPI
- 3050464585
- Location
- San Diego, CA · TIN 61-2250278
- Authorisation / referral
- PA2025293384 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,354.00 | $609.30 | — | — | DeniedCO29 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $135.00 | $60.75 | — | — | DeniedCO29 |
| Totals | $1,489.00 | $670.05 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-568109
- 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-033215 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-15: OPTIONS-PPO (PPO), effective 2024-07-01. | |
| Timely filing | Fail | CO29 | Received 168 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025293384 on file for 74177. | |
| 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: Northgate Imaging Center2025-12-15 17:24
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-06-01 00:09
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2025293384_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-12-15 to 2026-03-15.
- Itemized billitemized_PA-568109.pdf5 pages
Itemised statement totalling $1489.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 168 days after the last date of service (limit 90). 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
Received after the timely-filing limit.