CLM-2026-019471
Canyon Diagnostic Imaging, Radiology. Service 2026-05-26 at outpatient hospital (POS 22). Received 2026-07-13.
Member
Resolved through the identity graph
- Member
- Christian James
- Member ID
- UHC-82723-91
- Date of birth
- 1977-10-08
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-418666
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group -
- Coverage period
- 2021-07-01 to present
- Deductible
- $1,998.39 of $2,500.0080%
- Out-of-pocket maximum
- $2,011.80 of $5,000.0040%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
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 | $184.00 | $101.20 | — | — | DeniedCO18 |
| Totals | $184.00 | $101.20 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-119372
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026393 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-26: NULL (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 48 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-019470: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Imaging2026-05-26 18:03
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-13 02:27
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-13 11:31
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-119372.pdf7 pages
Itemised statement totalling $184.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-019470: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019470 | 2026-05-26 | Canyon Diagnostic Imaging | $184.00 | Approved |
| CLM-2026-000681 | 2026-04-12 | Summit Regional Medical Center | $4,043.00 | Approved |
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
Exact duplicate of an earlier submission.