CLM-2026-018832
Unity Diagnostic Imaging, Radiology. Service 2026-04-03 at outpatient hospital (POS 22). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Heather Walsh
- Member ID
- none on golden record
- Date of birth
- 1942-10-11
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-403782
- Relationship
- Child
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-8956
- Coverage period
- 2023-12-01 to present
- Deductible
- $476.67 of $1,500.0032%
- Out-of-pocket maximum
- $771.99 of $3,000.0026%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1910682917
- Network
- In network
- Rendering NPI
- 1910682917
- Location
- Mesa, AZ · TIN 81-0269629
- Authorisation / referral
- PA2025563324 / 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 | $2,065.00 | $1,135.75 | — | — | PendedIDQ |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $540.00 | $297.00 | — | — | PendedIDQ |
| Totals | $2,605.00 | $1,432.75 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-336341
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000011; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-04-03: SELECT-EPO (EPO), effective 2023-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025563324 on file for 74177. | |
| Provider network | Pass | In-network provider Unity Diagnostic Imaging (1910682917). | |
| 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: Unity Diagnostic Imaging2026-04-03 10:37
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025563324_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-04-03 to 2026-07-02.
- Itemized billitemized_PA-336341.pdf6 pages
Itemised statement totalling $2605.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000011; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-03: SELECT-EPO (EPO), effective 2023-12-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.