CLM-2026-016526
Evergreen Diagnostic Imaging, Radiology. Service 2026-02-27 at outpatient hospital (POS 22). Received 2026-03-14.
Member
Resolved through the identity graph
- Member
- Hannah Flores
- Member ID
- UHC-13128-47
- Date of birth
- 1954-07-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-430203
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3543
- Coverage period
- 2024-06-01 to present
- Deductible
- $410.93 of $1,500.0027%
- Out-of-pocket maximum
- $95.15 of $3,000.003%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 7098075170
- Network
- In network
- Rendering NPI
- 7098075170
- Location
- Atlanta, GA · TIN 75-1814880
- Authorisation / referral
- PA2026881804 / 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 | $2,242.00 | $1,233.10 | — | — | Review |
| Totals | $2,242.00 | $1,233.10 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-612580
- 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-019565 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-27: N/A (PPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026881804 on file for 70553. | |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (7098075170). | |
| Medical necessity | Review | CO50 | 70553 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: Evergreen Diagnostic Imaging2026-02-27 16:36
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 letterPA2026881804_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-02-27 to 2026-05-28.
- Itemized billitemized_PA-612580.pdf3 pages
Itemised statement totalling $2242.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 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-2026-016641 | 2026-02-07 | Mesa Dermatology Clinic | $2,258.00 | Needs review |
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.