CLM-2026-015936
Northgate Imaging Center, Radiology. Service 2025-12-15 at outpatient hospital (POS 22). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Peter Kelly
- Member ID
- UHC-28833-25
- Date of birth
- 1981-07-09
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-407678
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3857
- Coverage period
- 2021-11-01 to present
- Deductible
- $2,191.37 of $3,500.0063%
- Out-of-pocket maximum
- $654.94 of $10,500.006%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 20 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
- PA2026700257 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $364.00 | $163.80 | — | — | Review |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,705.00 | $767.25 | — | — | Review |
| Totals | $2,069.00 | $931.05 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-733658
- 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-002230 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-15: OPTIONS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026700257 on file for 74177. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Review | CO50 | 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 09:17
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026700257_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2025-12-15 to 2026-03-15.
- Itemized billitemized_PA-733658.pdf6 pages
Itemised statement totalling $2069.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
- AI recommendationPended2026-10-21 14:15The claim for a CT scan (74177) with a routine diagnosis (Z12.31) has been flagged for medical necessity. The clinical notes provided do not explicitly support the necessity of the CT scan for the given diagnosis. The claim should be pended to verify if the clinical notes indeed support the medical necessity of the CT scan.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · a8553a9b
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021905 | 2026-02-06 | Harbor Medical Group | $249.00 | Approved |
| CLM-2026-008447 | 2025-12-25 | Northgate Internal Medicine Associates | $296.00 | Approved |
| CLM-2026-015937 | 2025-12-15 | Northgate Imaging Center | $2,069.00 | Needs review |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO50 Not medically necessary per payer policy
The claim for a CT scan (74177) with a routine diagnosis (Z12.31) has been flagged for medical necessity. The clinical notes provided do not explicitly support the necessity of the CT scan for the given diagnosis. The claim should be pended to verify if the clinical notes indeed support the medical necessity of the CT scan.
- Verify if the clinical notes support the medical necessity of the CT scan (74177) given the routine diagnosis.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO50 Not medically necessary per payer policy
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.