CLM-2026-022074
Desert Imaging Center, Radiology. Service 2025-10-10 at outpatient hospital (POS 22). Received 2026-01-25.
Member
Resolved through the identity graph
- Member
- Nancy Evans
- Member ID
- UHC-89861-37
- Date of birth
- 1955-07-19
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-411106
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4567
- Coverage period
- 2022-10-01 to present
- Deductible
- $1,432.31 of $2,500.0057%
- Out-of-pocket maximum
- $2,516.04 of $10,000.0025%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3553360983
- Network
- In network
- Rendering NPI
- 3553360983
- Location
- Atlanta, GA · TIN 73-9549264
- Authorisation / referral
- PA2026067051 / 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 | $2,402.00 | $1,321.10 | — | — | DeniedCO29 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $116.00 | $63.80 | — | — | DeniedCO29 |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1,2 | $499.00 | $274.45 | — | — | DeniedCO29 |
| Totals | $3,017.00 | $1,659.35 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-671854
- 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-001210 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-10-10: OPTIONS-PPO (PPO), effective 2022-10-01. | |
| Timely filing | Fail | CO29 | Received 107 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 | Authorisation PA2026067051 on file for 74177. | |
| Provider network | Pass | In-network provider Desert Imaging Center (3553360983). | |
| 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 Imaging Center2025-10-10 10:54
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-01-25 00:14
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026067051_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-10-10 to 2026-01-08.
- Itemized billitemized_PA-671854.pdf8 pages
Itemised statement totalling $3017.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 107 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.