CLM-2026-016369
Summit Diagnostic Imaging, Radiology. Service 2026-06-24 at outpatient hospital (POS 22). Received 2026-07-18.
Member
Resolved through the identity graph
- Member
- Marcus Burke
- Member ID
- UHC-79080-92
- Date of birth
- 2008-04-17
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412861
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5737
- Coverage period
- 2025-11-01 to present
- Deductible
- $499.10 of $2,500.0020%
- Out-of-pocket maximum
- $667.23 of $7,500.009%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8935049519
- Network
- In network
- Rendering NPI
- 8935049519
- Location
- Los Angeles, CA · TIN 90-8085018
- Authorisation / referral
- none / 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 | $1,833.00 | $1,008.15 | — | — | DeniedCO197 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $194.00 | $106.70 | — | — | DeniedCO197 |
| Totals | $2,027.00 | $1,114.85 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-757474
- 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-022218 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-24: MEDICARE-ADV-A (MA), effective 2025-11-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Summit Diagnostic Imaging (8935049519). | |
| 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: Summit Diagnostic Imaging2026-06-24 13:27
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
- SystemSystem: Claims system2026-07-18 00:51
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-757474.pdf8 pages
Itemised statement totalling $2027.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 74177 require precertification; no authorisation number on the claim. Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
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.