CLM-2026-018911
Canyon Diagnostic Imaging, Radiology. Service 2026-08-22 at outpatient hospital (POS 22). Received 2026-08-24.
Member
Resolved through the identity graph
- Member
- Christina Nelson
- Member ID
- none on golden record
- Date of birth
- 1904-05-19
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-412793
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1352145704
- Network
- In network
- Rendering NPI
- 1352145704
- Location
- Atlanta, GA · TIN 24-1782323
- Authorisation / referral
- none / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $238.00 | $130.90 | — | — | DeniedCO197 |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $2,512.00 | $1,381.60 | — | — | DeniedCO197 |
| Totals | $2,750.00 | $1,512.50 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-450499
- 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 | Pass | Attached to MBR-042417 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 2 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (1352145704). | |
| 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: Canyon Diagnostic Imaging2026-08-22 17:42
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-24 06:02
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-24 08:51
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-450499.pdf9 pages
Itemised statement totalling $2750.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim. Prior authorisation: 70553 require precertification; no authorisation number on the claim.
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
Precertification required and absent.