CLM-2026-020444
Canyon Diagnostic Imaging, Radiology. Service 2026-05-23 at outpatient hospital (POS 22). Received 2026-06-21.
Member
Resolved through the identity graph
- Member
- Billy Homles
- Member ID
- none on golden record
- Date of birth
- 1941-01-13
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-409650
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Eligibility
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
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $202.00 | $111.10 | — | — | PendedN30 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | 25 | 1 | 1 | $384.00 | $211.20 | — | — | PendedN30 |
| Totals | $586.00 | $322.30 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-526230
- 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-035799 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 29 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 | 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 Imaging2026-05-23 10:46
Patient seen for unspecified abdominal pain. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-21 05:29
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-526230.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-526230.pdf7 pages
Itemised statement totalling $586.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim.
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
Authorisation must be confirmed with UM before payment.