CLM-2026-019931
Desert Diagnostic Imaging, Radiology. Service 2026-08-22 at outpatient hospital (POS 22). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Sandra Wallace
- Member ID
- UHC-92839-30
- Date of birth
- 1943-05-15
- Identity
- Verified4 records, confidence 0.85
- Claim record
- CLMCLM-402708
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group NULL
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,270.77 of $1,500.0085%
- Out-of-pocket maximum
- $889.96 of $3,000.0030%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3515366425
- Network
- In network
- Rendering NPI
- 7696270280 (Valley Imaging Center)
- Location
- Phoenix, AZ · TIN 68-2801174
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $630.00 | $346.50 | — | — | Review |
| Totals | $630.00 | $346.50 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-639410
- 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-001546 (verified, link confidence 0.85). | |
| Eligibility | Pass | Active on 2026-08-22: MEDICARE-ADV-A (MA), effective 2025-04-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-019930, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (3515366425). | |
| 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: Desert Diagnostic Imaging2026-08-22 12:01
Patient seen for pain in right knee. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-10-04 06:09
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
- Itemized billitemized_PA-639410.pdf4 pages
Itemised statement totalling $630.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-019930, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019930 | 2026-08-22 | Valley Imaging Center | $630.00 | Approved |
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
Different billing provider; separately payable.