CLM-2026-022468
Summit Imaging Center, Radiology. Service 2026-07-15 at outpatient hospital (POS 22). Received 2026-08-04.
Member
Resolved through the identity graph
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6637
- Coverage period
- 2021-05-01 to present
- Deductible
- $299.11 of $1,000.0030%
- Out-of-pocket maximum
- $1,268.09 of $4,000.0032%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4562878908
- Network
- In network
- Rendering NPI
- 4562878908
- Location
- Minneapolis, MN · TIN 57-8653616
- Authorisation / referral
- PA2026297794 / 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $288.00 | $158.40 | — | — | PendedCO16 |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $2,529.00 | $1,390.95 | — | — | PendedCO16 |
| Totals | $2,817.00 | $1,549.35 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-869583
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | CO16 | Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication |
| Eligibility | Pass | Active on 2026-07-15: NAVIGATE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026297794 on file for 70553. | |
| Provider network | Pass | In-network provider Summit Imaging Center (4562878908). | |
| Medical necessity | Review | CO50 | 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: Summit Imaging Center2026-07-15 15:08
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026297794_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-07-15 to 2026-10-13.
- Itemized billitemized_PA-869583.pdf6 pages
Itemised statement totalling $2817.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Claim record is not attached to a resolved identity. Medical necessity: 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.