CLM-2026-019379
Desert Diagnostic Imaging, Radiology. Service 2025-11-19 at outpatient hospital (POS 22). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Margaret Weaver
- Member ID
- UHC-13952-43
- Date of birth
- 1989-04-17
- Identity
- Verified6 records, confidence 0.98
- Claim record
- CLMCLM-426454
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1126
- Coverage period
- 2022-10-01 to present
- Deductible
- $1,169.69 of $2,500.0047%
- Out-of-pocket maximum
- $2,063.51 of $10,000.0021%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 2571625872
- Network
- In network
- Rendering NPI
- 2571625872
- Location
- Dallas, TX · TIN 43-0454627
- Authorisation / referral
- PA2026879222 / 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 | $2,538.00 | $1,395.90 | — | — | Review |
| Totals | $2,538.00 | $1,395.90 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-235506
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000298 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2025-11-19: OPTIONS-PPO (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026879222 on file for 74177. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (2571625872). | |
| Medical necessity | Review | CO50 | 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Diagnostic Imaging2025-11-19 18:16
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026879222_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-11-19 to 2026-02-17.
- Itemized billitemized_PA-235506.pdf8 pages
Itemised statement totalling $2538.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
- AI recommendationPended2026-10-21 14:05The claim for a CT abdomen and pelvis with contrast (74177) was flagged for medical necessity (CO50) as it was billed with a routine diagnosis (Z12.31). The clinical note indicates the patient is presenting for a screening mammogram, which is a routine procedure. The rules engine requires clinical notes to support the necessity of the CT scan in this context. The prior authorisation is on file, but the clinical necessity must be confirmed. The claim is pended to verify if the clinical note supports the medical necessity of the CT scan for a routine screening mammogram.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 5c888c1c
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004029 | 2026-05-27 | Mesa Physical Therapy | $276.00 | Approved |
| CLM-2026-026660 | 2026-05-30 | Northgate Internal Medicine Associates | $277.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO50 Not medically necessary per payer policy
The claim for a CT abdomen and pelvis with contrast (74177) was flagged for medical necessity (CO50) as it was billed with a routine diagnosis (Z12.31). The clinical note indicates the patient is presenting for a screening mammogram, which is a routine procedure. The rules engine requires clinical notes to support the necessity of the CT scan in this context. The prior authorisation is on file, but the clinical necessity must be confirmed. The claim is pended to verify if the clinical note supports the medical necessity of the CT scan for a routine screening mammogram.
- Verify if the clinical note supports the medical necessity of the CT scan for a routine screening mammogram.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO50 Not medically necessary per payer policy
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.