CLM-2026-019500
Canyon Diagnostic Imaging, Radiology. Service 2026-04-15 at outpatient hospital (POS 22). Received 2026-05-21.
Member
Resolved through the identity graph
- Member
- Ronald Meyer
- Member ID
- none on golden record
- Date of birth
- 2000-05-27
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-431866
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-3240
- Coverage period
- 2025-01-01 to present
- Deductible
- $286.43 of $1,000.0029%
- Out-of-pocket maximum
- $401.49 of $2,000.0020%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 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
- PA2025913980 / 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 | $1,417.00 | $779.35 | — | — | PendedIDQ |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $233.00 | $128.15 | — | — | PendedIDQ |
| Totals | $1,650.00 | $907.50 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-365518
- 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 | Fail | IDQ | Member record is in open steward case CASE-000529; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-04-15: OPTIONS-PPO (PPO), effective 2025-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025913980 on file for 74177. | |
| 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 Imaging2026-04-15 15:57
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025913980_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-04-15 to 2026-07-14.
- Itemized billitemized_PA-365518.pdf7 pages
Itemised statement totalling $1650.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000529; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-15: OPTIONS-PPO (PPO), effective 2025-01-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.