CLM-2026-016226
Desert Imaging Center, Radiology. Service 2026-01-30 at outpatient hospital (POS 22). Received 2026-02-18.
Member
Resolved through the identity graph
- Member
- Willie Price
- Member ID
- UHC-51717-16
- Date of birth
- 1946-06-09
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-404176
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-4940
- Coverage period
- 2024-09-01 to present
- Deductible
- $689.90 of $1,000.0069%
- Out-of-pocket maximum
- $1,228.07 of $3,000.0041%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3553360983
- Network
- In network
- Rendering NPI
- 3553360983
- Location
- Atlanta, GA · TIN 73-9549264
- Authorisation / referral
- PA2026905360 / 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 | $612.00 | $336.60 | $315.40 | $21.20 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $3,060.00 | $1,683.00 | $336.60 | $1,346.40 | Paid |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,967.00 | $1,081.85 | $216.37 | $865.48 | Paid |
| Totals | $5,639.00 | $3,101.45 | $868.37 | $2,233.08 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-570005
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014007 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-30: N/A (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026905360 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Desert Imaging Center (3553360983). | |
| 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: Desert Imaging Center2026-01-30 12:07
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026905360_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-01-30 to 2026-04-30.
- Itemized billitemized_PA-570005.pdf6 pages
Itemised statement totalling $5639.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013690 | 2026-09-09 | Pinecrest Primary Care Associates | $185.00 | Approved |
| CLM-2026-029629 | 2026-05-18 | Heritage Internal Medicine Associates | $272.00 | Approved |
| CLM-2026-023143 | 2026-03-31 | Unity Clinical Laboratories | $134.00 | Approved |
| CLM-2026-013636 | 2026-02-07 | Heritage Primary Care Associates | $293.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.