CLM-2026-019549
Canyon Diagnostic Imaging, Radiology. Service 2026-06-10 at outpatient hospital (POS 22). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Ashley Bradley
- Member ID
- UHC-66935-98
- Date of birth
- 1956-04-18
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-417827
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5867
- Coverage period
- 2021-07-01 to present
- Deductible
- $824.81 of $2,500.0033%
- Out-of-pocket maximum
- $2,121.45 of $7,500.0028%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 8 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
- PA2026515684 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,510.00 | $1,380.50 | $1,380.50 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $286.00 | $157.30 | $157.30 | $0.00 | Paid |
| Totals | $2,796.00 | $1,537.80 | $1,537.80 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-743323
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000890 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-10: NULL (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026515684 on file for 70553. | |
| 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 Imaging2026-06-10 09:36
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026515684_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-10 to 2026-09-08.
- Itemized billitemized_PA-743323.pdf9 pages
Itemised statement totalling $2796.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011975 | 2026-09-29 | Valley Rehabilitation Center | $444.00 | Approved |
| CLM-2026-008235 | 2026-06-24 | Valley Rehabilitation Center | $301.00 | Approved |
| CLM-2026-023906 | 2026-05-27 | Sunrise Medical Group | $325.00 | Approved |
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.