CLM-2026-022297
Riverside Imaging Center, Radiology. Service 2025-12-01 at outpatient hospital (POS 22). Received 2026-01-13.
Member
Resolved through the identity graph
- Member
- Theresa West
- Member ID
- UHC-07177-15
- Date of birth
- 1982-03-22
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-402189
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3491
- Coverage period
- 2021-10-01 to present
- Deductible
- $391.35 of $1,000.0039%
- Out-of-pocket maximum
- $713.97 of $2,000.0036%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7427092680
- Network
- In network
- Rendering NPI
- 7427092680
- Location
- Mesa, AZ · TIN 33-8428995
- Authorisation / referral
- PA2025585799 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $433.00 | $238.15 | $238.15 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,609.00 | $1,434.95 | $689.84 | $745.11 | Paid |
| Totals | $3,042.00 | $1,673.10 | $927.99 | $745.11 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-733043
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003519 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-01: SELECT-EPO (EPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025585799 on file for 70553. | |
| Provider network | Pass | In-network provider Riverside Imaging Center (7427092680). | |
| 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: Riverside Imaging Center2025-12-01 18:42
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025585799_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2025-12-01 to 2026-03-01.
- Itemized billitemized_PA-733043.pdf6 pages
Itemised statement totalling $3042.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004712 | 2026-05-31 | Mesa Orthopedic Specialists | $11,732.00 | Approved |
| CLM-2026-016878 | 2026-01-10 | Desert Reference Lab | $119.00 | 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.