CLM-2026-021449
Valley Imaging Center, Radiology. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-02-04.
Member
Resolved through the identity graph
- Member
- Jonathan Brooks
- Member ID
- UHC-27135-67
- Date of birth
- 1999-03-02
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-428366
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8485
- Coverage period
- 2022-10-01 to present
- Deductible
- $309.35 of $3,500.009%
- Out-of-pocket maximum
- $2,103.99 of $14,000.0015%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7696270280
- Network
- In network
- Rendering NPI
- 7696270280
- Location
- Scottsdale, AZ · TIN 61-0618370
- Authorisation / referral
- PA2026015998 / REF838892
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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,169.00 | $1,192.95 | $1,192.95 | $0.00 | Paid |
| Totals | $2,169.00 | $1,192.95 | $1,192.95 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-740062
- 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-010243 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-08: CORE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026015998 on file for 74177. | |
| Provider network | Pass | In-network provider Valley Imaging Center (7696270280). | |
| 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: Valley Imaging Center2026-01-08 18:33
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026015998_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-01-08 to 2026-04-08.
- Itemized billitemized_PA-740062.pdf5 pages
Itemised statement totalling $2169.00 across 1 line.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016347 | 2026-07-18 | Desert Medical Group | $31.00 | Approved |
| CLM-2026-034258 | 2026-05-31 | Evergreen GI Associates | $2,159.00 | Approved |
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.