CLM-2026-022572
Desert Diagnostic Imaging, Radiology. Service 2025-12-21 at outpatient hospital (POS 22). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Donald Johnston
- Member ID
- UHC-99698-01
- Date of birth
- 1945-11-27
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-401364
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9326
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,009.45 of $3,500.0029%
- Out-of-pocket maximum
- $4,785.01 of $10,500.0046%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 2571625872
- Network
- In network
- Rendering NPI
- 2571625872
- Location
- Dallas, TX · TIN 43-0454627
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $593.00 | $326.15 | $326.15 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $173.00 | $95.15 | $95.15 | $0.00 | Paid |
| Totals | $766.00 | $421.30 | $421.30 | $0.00 | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-137538
- 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-003330 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-21: OPTIONS-PPO (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (2571625872). | |
| 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 Imaging2025-12-21 16:23
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Itemized billitemized_PA-137538.pdf5 pages
Itemised statement totalling $766.00 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
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.