CLM-2026-018960
Desert Imaging Center, Radiology. Service 2026-07-24 at outpatient hospital (POS 22). Received 2026-08-05.
Member
Resolved through the identity graph
- Member
- Janet Arnold
- Member ID
- UHC-22906-03
- Date of birth
- 1996-04-01
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-426121
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7671
- Coverage period
- 2023-12-01 to present
- Deductible
- $273.89 of $1,500.0018%
- Out-of-pocket maximum
- $1,131.85 of $6,000.0019%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 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
- 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 | $176.00 | $96.80 | $96.80 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | 25 | 1 | 2 | $389.00 | $213.95 | $213.95 | $0.00 | Paid |
| Totals | $565.00 | $310.75 | $310.75 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-183967
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028997 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-24: MEDICARE-ADV-B (MA), effective 2023-12-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-07-24 10:27
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-183967.pdf3 pages
Itemised statement totalling $565.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.