CLM-2026-020166
Mesa Imaging Center, Radiology. Service 2026-06-08 at outpatient hospital (POS 22). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Grace Knight
- Member ID
- UHC-20430-16
- Date of birth
- 1976-05-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-405562
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-0865
- Coverage period
- 2023-01-01 to present
- Deductible
- $844.30 of $3,500.0024%
- Out-of-pocket maximum
- $778.08 of $7,000.0011%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 6656135814
- Network
- Out of network
- Rendering NPI
- 6656135814
- Location
- Minneapolis, MN · TIN 75-3868074
- Authorisation / referral
- PA2026322025 / 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 | $523.00 | $235.35 | $235.35 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $1,918.00 | $863.10 | $863.10 | $0.00 | Paid |
| 3 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $227.00 | $102.15 | $102.15 | $0.00 | Paid |
| Totals | $2,668.00 | $1,200.60 | $1,200.60 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-751165
- 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-016211 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-08: UNKNOWN (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026322025 on file for 74177. | |
| 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: Mesa Imaging Center2026-06-08 18:38
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026322025_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-06-08 to 2026-09-06.
- Itemized billitemized_PA-751165.pdf7 pages
Itemised statement totalling $2668.00 across 3 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.