CLM-2026-019179
Northgate Imaging Center, Radiology. Service 2026-08-01 at outpatient hospital (POS 22). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Roy Brooks
- Member ID
- UHC-54707-20
- Date of birth
- 2006-11-27
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-425645
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1481
- Coverage period
- 2024-12-01 to 2026-05-17
- Deductible
- $758.66 of $1,000.0076%
- Out-of-pocket maximum
- $230.23 of $3,000.008%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3050464585
- Network
- Out of network
- Rendering NPI
- 3050464585
- Location
- San Diego, CA · TIN 61-2250278
- Authorisation / referral
- none / REF731947
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 | $348.00 | $156.60 | — | — | DeniedCO27 |
| Totals | $348.00 | $156.60 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. R51.9 Headache, unspecified
- Patient account
- PA-247997
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007885 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-01 is after coverage terminated on 2026-05-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 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 | Fail | CO204 | Billing provider 3050464585 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Northgate Imaging Center2026-08-01 14:44
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-07 00:26
Attachments
Documents received with the claim
- Itemized billitemized_PA-247997.pdf9 pages
Itemised statement totalling $348.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-01 is after coverage terminated on 2026-05-17. Provider network: Billing provider 3050464585 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026631 | 2026-02-12 | Mesa Diabetes Center | $577.00 | Approved |
| CLM-2026-013098 | 2025-12-16 | Unity Primary Care Associates | $36.00 | Denied |
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.