CLM-2026-022533
Desert Diagnostic Imaging, Radiology. Service 2026-08-03 at outpatient hospital (POS 22). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Wei Kelley
- Member ID
- UHC-12042-09
- Date of birth
- 2004-02-10
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-423605
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group UNKNOWN
- Coverage period
- 2024-09-01 to present
- Deductible
- $195.74 of $500.0039%
- Out-of-pocket maximum
- $87.98 of $1,000.009%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3515366425
- Network
- In network
- Rendering NPI
- 3515366425
- Location
- Phoenix, AZ · TIN 68-2801174
- Authorisation / referral
- none / 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 | $356.00 | $195.80 | — | — | DeniedCO197 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 1 | $1,592.00 | $875.60 | — | — | DeniedCO197 |
| Totals | $1,948.00 | $1,071.40 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-781540
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015022 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-03: SELECT-EPO (EPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (3515366425). | |
| 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 Diagnostic Imaging2026-08-03 11:59
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-08-17 05:34
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-781540.pdf9 pages
Itemised statement totalling $1948.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 74177 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011688 | 2026-02-18 | Unity Community Hospital | $390.00 | Approved |
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
Precertification required and absent.