CLM-2026-015970
Valley Imaging Center, Radiology. Service 2026-10-01 at outpatient hospital (POS 22). Received 2026-10-15.
Member
Resolved through the identity graph
- Member
- George Kelley
- Member ID
- UHC-50392-85
- Date of birth
- 1982-01-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-422851
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6313
- Coverage period
- 2025-12-01 to present
- Deductible
- $346.09 of $1,000.0035%
- Out-of-pocket maximum
- $395.82 of $2,000.0020%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 5964910181
- Network
- In network
- Rendering NPI
- 5964910181
- Location
- Austin, TX · TIN 60-0192260
- Authorisation / referral
- PA2026976414 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,174.00 | $1,745.70 | — | — | Review |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,312.00 | $721.60 | — | — | Review |
| Totals | $4,486.00 | $2,467.30 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-580367
- 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-023857 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-01: CHOICE-PLUS-PPO (PPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026976414 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Valley Imaging Center (5964910181). | |
| Medical necessity | Review | CO50 | 70553, 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: Valley Imaging Center2026-10-01 16:23
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026976414_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-10-01 to 2026-12-30.
- Itemized billitemized_PA-580367.pdf4 pages
Itemised statement totalling $4486.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553, 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000607 | 2026-03-17 | Canyon Clinical Laboratories | $189.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.