CLM-2026-018313
Valley Imaging Center, Radiology. Service 2026-08-23 at outpatient hospital (POS 22). Received 2026-09-16.
Member
Resolved through the identity graph
- Member
- Jordan Harris
- Member ID
- UHC-98759-35
- Date of birth
- 1951-12-25
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-407328
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4869
- Coverage period
- 2023-09-01 to 2026-01-03
- Deductible
- $865.53 of $1,500.0058%
- Out-of-pocket maximum
- $1,238.37 of $3,000.0041%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 5964910181
- Network
- In network
- Rendering NPI
- 5964910181
- Location
- Austin, TX · TIN 60-0192260
- Authorisation / referral
- PA2026025278 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $333.00 | $183.15 | — | — | DeniedCO27 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,408.00 | $774.40 | — | — | DeniedCO27 |
| Totals | $1,741.00 | $957.55 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-179731
- 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-008289 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-23 is after coverage terminated on 2026-01-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026025278 on file for 74177. | |
| Provider network | Pass | In-network provider Valley Imaging Center (5964910181). | |
| 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: Valley Imaging Center2026-08-23 10:56
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-16 02:53
Attachments
Documents received with the claim
- Prior auth letterPA2026025278_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-08-23 to 2026-11-21.
- Itemized billitemized_PA-179731.pdf9 pages
Itemised statement totalling $1741.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-23 is after coverage terminated on 2026-01-03.
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.