CLM-2026-017742
Canyon Diagnostic Imaging, Radiology. Service 2026-02-16 at outpatient hospital (POS 22). Received 2026-03-15.
Member
Resolved through the identity graph
- Member
- Paul Bryant
- Member ID
- UHC-25714-67
- Date of birth
- 1975-01-19
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-421702
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4924
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,129.75 of $3,500.0032%
- Out-of-pocket maximum
- $2,525.22 of $7,000.0036%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8055565153
- Network
- In network
- Rendering NPI
- 8055565153
- Location
- Atlanta, GA · TIN 44-7708549
- Authorisation / referral
- PA2026121013 / 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 | $1,345.00 | $739.75 | $739.75 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $2,081.00 | $1,144.55 | $1,144.55 | $0.00 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $174.00 | $95.70 | $95.70 | $0.00 | Paid |
| Totals | $3,600.00 | $1,980.00 | $1,980.00 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-893398
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019832 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-02-16: SELECT-EPO (EPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026121013 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (8055565153). | |
| 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: Canyon Diagnostic Imaging2026-02-16 11:15
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026121013_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-02-16 to 2026-05-17.
- Itemized billitemized_PA-893398.pdf8 pages
Itemised statement totalling $3600.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014295 | 2026-06-23 | Desert Diagnostic Imaging | $2,302.00 | Approved |
| CLM-2026-021583 | 2026-05-08 | Sunrise Bone and Joint Center | $224.00 | 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.