CLM-2026-017747
Evergreen Diagnostic Imaging, Radiology. Service 2026-02-28 at outpatient hospital (POS 22). Received 2026-03-31.
Member
Resolved through the identity graph
- Member
- Christopher Graham
- Member ID
- UHC-23280-13
- Date of birth
- 1969-02-07
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425496
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5801
- Coverage period
- 2025-09-01 to present
- Deductible
- $1,016.21 of $1,500.0068%
- Out-of-pocket maximum
- $1,456.40 of $6,000.0024%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 4970897466
- Network
- In network
- Rendering NPI
- 4970897466
- Location
- Charlotte, NC · TIN 79-7771528
- Authorisation / referral
- PA2026972324 / REF982104
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 | $1,742.00 | $958.10 | $531.22 | $426.88 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1 | $123.00 | $67.65 | $6.77 | $60.88 | Paid |
| Totals | $1,865.00 | $1,025.75 | $537.99 | $487.76 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-754476
- 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-010905 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-28: NAVIGATE-HMO (HMO), effective 2025-09-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026972324 on file for 74177. | |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (4970897466). | |
| 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: Evergreen Diagnostic Imaging2026-02-28 15:15
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026972324_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-02-28 to 2026-05-29.
- Itemized billitemized_PA-754476.pdf6 pages
Itemised statement totalling $1865.00 across 2 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-2026-006971 | 2026-06-09 | Pinecrest Primary Care Associates | $830.00 | 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.