CLM-2026-020712
Desert Diagnostic Imaging, Radiology. Service 2026-09-20 at outpatient hospital (POS 22). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Maria Nunez
- Member ID
- UHC-05838-12
- Date of birth
- 1946-01-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-407810
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9364
- Coverage period
- 2023-08-01 to present
- Deductible
- $619.24 of $1,500.0041%
- Out-of-pocket maximum
- $1,174.98 of $4,500.0026%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3515366425
- Network
- In network
- Rendering NPI
- 3515366425
- Location
- Phoenix, AZ · TIN 68-2801174
- Authorisation / referral
- PA2025098617 / REF617428
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 | $353.00 | $194.15 | $194.15 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $194.00 | $106.70 | $106.70 | $0.00 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 1 | $3,494.00 | $1,921.70 | $714.09 | $1,207.61 | Paid |
| Totals | $4,041.00 | $2,222.55 | $1,014.94 | $1,207.61 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-661630
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031541 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-20: CORE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025098617 on file for 70553. | |
| 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 Imaging2026-09-20 17:04
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025098617_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-09-20 to 2026-12-19.
- Itemized billitemized_PA-661630.pdf3 pages
Itemised statement totalling $4041.00 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 12:44Clean claim.
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.