CLM-2026-017874
Riverside Diagnostic Imaging, Radiology. Service 2026-08-05 at outpatient hospital (POS 22). Received 2026-09-11.
Member
Resolved through the identity graph
- Member
- Kate Walsh
- Member ID
- UHC-91901-69
- Date of birth
- 1950-09-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416833
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9929
- Coverage period
- 2023-10-01 to 2026-08-04
- Deductible
- $28.42 of $500.006%
- Out-of-pocket maximum
- $327.96 of $2,000.0016%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6802768252
- Network
- In network
- Rendering NPI
- 6802768252
- Location
- Scottsdale, AZ · TIN 85-0998777
- Authorisation / referral
- PA2025254800 / 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 | $1,955.00 | $1,075.25 | — | — | DeniedCO27 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $168.00 | $92.40 | — | — | DeniedCO27 |
| Totals | $2,123.00 | $1,167.65 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-286526
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-043919 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-05 is after coverage terminated on 2026-08-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025254800 on file for 74177. | |
| Provider network | Pass | In-network provider Riverside Diagnostic Imaging (6802768252). | |
| 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: Riverside Diagnostic Imaging2026-08-05 14:36
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-09-11 03:54
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-11 12:05
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025254800_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-05 to 2026-11-03.
- Itemized billitemized_PA-286526.pdf9 pages
Itemised statement totalling $2123.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-05 is after coverage terminated on 2026-08-04.
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
Service after coverage termination.