CLM-2026-021608
Valley Imaging Center, Radiology. Service 2026-04-28 at outpatient hospital (POS 22). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Gabriel Robertson
- Member ID
- UHC-65311-64
- Date of birth
- 1946-05-09
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-401399
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7294
- Coverage period
- 2023-02-01 to present
- Deductible
- $379.68 of $1,500.0025%
- Out-of-pocket maximum
- $300.42 of $4,500.007%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 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
- PA2026034908 / REF750729
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 | $1,579.00 | $868.45 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,228.00 | $1,225.40 | — | — | Review |
| Totals | $3,807.00 | $2,093.85 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-390523
- 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-001760 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-28: NAVIGATE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026034908 on file for 74177, 70553. | |
| 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 | Review | CO16 | Documentation incomplete: “Patient seen for unspecified abdominal pain. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Imaging Center2026-04-28 12:02
Patient seen for unspecified abdominal pain. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-07 00:05
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-07 13:41
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026034908_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-04-28 to 2026-07-27.
- Itemized billitemized_PA-390523.pdf6 pages
Itemised statement totalling $3807.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for unspecified abdominal pain. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034460 | 2026-05-02 | Riverside Internal Medicine Associates | $293.00 | Denied |
| CLM-2026-034459 | 2026-05-02 | Heritage Medical Group | $293.00 | Approved |
| CLM-2026-011533 | 2026-02-17 | Desert Regional Medical Center | $1,061.00 | Approved |
| CLM-2026-003253 | 2025-12-25 | Desert Internal Medicine Associates | $2,210.00 | Needs review |
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
Development letter outstanding.