CLM-2026-022582
Summit Diagnostic Imaging, Radiology. Service 2026-04-23 at outpatient hospital (POS 22). Received 2026-05-09.
Member
Resolved through the identity graph
- Member
- Emily Hudson
- Member ID
- UHC-12967-87
- Date of birth
- 1963-09-10
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-400886
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1294
- Coverage period
- 2021-04-01 to present
- Deductible
- $344.37 of $1,500.0023%
- Out-of-pocket maximum
- $567.48 of $3,000.0019%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8935049519
- Network
- In network
- Rendering NPI
- 8935049519
- Location
- Los Angeles, CA · TIN 90-8085018
- Authorisation / referral
- none / REF469354
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 | $417.00 | $229.35 | — | — | DeniedCO197 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $1,934.00 | $1,063.70 | — | — | DeniedCO197 |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $579.00 | $318.45 | — | — | DeniedCO197 |
| Totals | $2,930.00 | $1,611.50 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-742896
- 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-028675 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-23: CORE-HMO (HMO), effective 2021-04-01. | |
| Timely filing | Pass | Received 16 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 Summit Diagnostic Imaging (8935049519). | |
| 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: Summit Diagnostic Imaging2026-04-23 11:13
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-05-09 04:56
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-742896.pdf6 pages
Itemised statement totalling $2930.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 74177 require precertification; no authorisation number on the claim.
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
Precertification required and absent.