CLM-2026-018279
Desert Imaging Center, Radiology. Service 2026-03-29 at outpatient hospital (POS 22). Received 2026-07-10.
Member
Resolved through the identity graph
- Member
- Diane Parker
- Member ID
- UHC-42042-21
- Date of birth
- 2001-10-18
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-419320
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6811
- Coverage period
- 2022-01-01 to present
- Deductible
- $359.05 of $500.0072%
- Out-of-pocket maximum
- $498.37 of $2,000.0025%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7235030955
- Network
- In network
- Rendering NPI
- 7235030955
- Location
- San Diego, CA · TIN 44-8505123
- Authorisation / referral
- PA2025948747 / 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 | $1,659.00 | $912.45 | — | — | DeniedCO29 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1,2 | $336.00 | $184.80 | — | — | DeniedCO29 |
| Totals | $1,995.00 | $1,097.25 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-436052
- 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-021416 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-29: NULL (PPO), effective 2022-01-01. | |
| Timely filing | Fail | CO29 | Received 103 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025948747 on file for 74177. | |
| Provider network | Pass | In-network provider Desert Imaging Center (7235030955). | |
| 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: Desert Imaging Center2026-03-29 15:59
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-10 06:48
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2025948747_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-03-29 to 2026-06-27.
- Itemized billitemized_PA-436052.pdf7 pages
Itemised statement totalling $1995.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 103 days after the last date of service (limit 90).
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
Received after the timely-filing limit.