CLM-2026-019651
Northgate Imaging Center, Radiology. Service 2026-02-14 at outpatient hospital (POS 22). Received 2026-03-19.
Member
Resolved through the identity graph
- Member
- David Jones
- Member ID
- UHC-24557-62
- Date of birth
- 1953-05-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412966
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group N/A
- Coverage period
- 2025-01-01 to present
- Deductible
- $2,199.69 of $2,500.0088%
- Out-of-pocket maximum
- $1,054.55 of $5,000.0021%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 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 / 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $411.00 | $184.95 | $184.95 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $350.00 | $157.50 | $128.00 | $29.50 | Paid |
| Totals | $761.00 | $342.45 | $312.95 | $29.50 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-345788
- 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-020761 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-14: MEDICARE-ADV-A (MA), effective 2025-01-01. | |
| Timely filing | Pass | Received 33 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Center2026-02-14 17:24
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-345788.pdf3 pages
Itemised statement totalling $761.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.