CLM-2026-021475
Canyon Diagnostic Imaging, Radiology. Service 2026-05-05 at outpatient hospital (POS 22). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Nathan Reynolds
- Member ID
- UHC-87757-33
- Date of birth
- 1964-03-05
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-425630
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5619
- Coverage period
- 2025-04-01 to present
- Deductible
- $2,867.04 of $3,500.0082%
- Out-of-pocket maximum
- $1,397.97 of $14,000.0010%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6871661313
- Network
- In network
- Rendering NPI
- 6871661313
- Location
- Tampa, FL · TIN 87-4174394
- Authorisation / referral
- PA2026147461 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,379.00 | $1,308.45 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,279.00 | $1,803.45 | — | — | Review |
| Totals | $5,658.00 | $3,111.90 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-983113
- 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-034511 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-05: MEDICARE-ADV-A (MA), effective 2025-04-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026147461 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (6871661313). | |
| Medical necessity | Review | CO50 | 74177, 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Imaging2026-05-05 10:57
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Prior auth letterPA2026147461_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-05-05 to 2026-08-03.
- Itemized billitemized_PA-983113.pdf7 pages
Itemised statement totalling $5658.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 74177, 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
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
Clean claim, priced at contract rate.