CLM-2026-021071
Desert Diagnostic Imaging, Radiology. Service 2026-04-29 at outpatient hospital (POS 22). Received 2026-08-19.
Member
Resolved through the identity graph
- Member
- Elizabeth Nelson
- Member ID
- UHC-53683-17
- Date of birth
- 1951-12-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418507
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1063
- Coverage period
- 2022-10-01 to present
- Deductible
- $823.59 of $1,000.0082%
- Out-of-pocket maximum
- $900.14 of $4,000.0023%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 2571625872
- Network
- In network
- Rendering NPI
- 2571625872
- Location
- Dallas, TX · TIN 43-0454627
- 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 | $340.00 | $187.00 | — | — | DeniedCO29 |
| Totals | $340.00 | $187.00 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-628166
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032900 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-29: MEDICARE-ADV-B (MA), effective 2022-10-01. | |
| Timely filing | Fail | CO29 | Received 112 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (2571625872). | |
| 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 Imaging2026-04-29 10:19
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-08-19 06:30
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-19 08:41
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-628166.pdf9 pages
Itemised statement totalling $340.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 112 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.