CLM-2026-016517
Harbor Diagnostic Imaging, Radiology. Service 2026-05-01 at outpatient hospital (POS 22). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Christopher Austin
- Member ID
- UHC-46437-23
- Date of birth
- 1944-12-09
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-405736
- Relationship
- Child, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3108
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,333.71 of $1,500.0089%
- Out-of-pocket maximum
- $2,224.02 of $6,000.0037%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1623659319
- Network
- In network
- Rendering NPI
- 1623659319
- Location
- Houston, TX · TIN 54-3766877
- Authorisation / referral
- PA2025909019 / REF159860
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 | $1,998.00 | $1,098.90 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $205.00 | $112.75 | — | — | Review |
| Totals | $2,203.00 | $1,211.65 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-217018
- 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-032436 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-05-01: CORE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025909019 on file for 74177. | |
| Provider network | Pass | In-network provider Harbor Diagnostic Imaging (1623659319). | |
| 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: Harbor Diagnostic Imaging2026-05-01 12:24
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 letterPA2025909019_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-05-01 to 2026-07-30.
- Itemized billitemized_PA-217018.pdf9 pages
Itemised statement totalling $2203.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 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-2026-025360 | 2026-06-04 | Harbor Medical Group | $328.00 | 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.