CLM-2026-022728
Unity Diagnostic Imaging, Radiology. Service 2026-03-16 at outpatient hospital (POS 22). Received 2026-03-28.
Member
Resolved through the identity graph
- Member
- Elijah Wood
- Member ID
- UHC-55725-25
- Date of birth
- 1984-09-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-427390
- Relationship
- Child, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group NULL
- Coverage period
- 2021-11-01 to present
- Deductible
- $16.47 of $2,500.001%
- Out-of-pocket maximum
- $1,197.34 of $5,000.0024%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1910682917
- Network
- In network
- Rendering NPI
- 1910682917
- Location
- Mesa, AZ · TIN 81-0269629
- Authorisation / referral
- PA2026630278 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,055.00 | $1,130.25 | $1,130.25 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $246.00 | $135.30 | $135.30 | $0.00 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,549.00 | $1,401.95 | $1,254.77 | $147.18 | Paid |
| Totals | $4,850.00 | $2,667.50 | $2,520.32 | $147.18 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-729194
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022615 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-16: CHOICE-PLUS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026630278 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Unity Diagnostic Imaging (1910682917). | |
| 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: Unity Diagnostic Imaging2026-03-16 11:44
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026630278_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-03-16 to 2026-06-14.
- Itemized billitemized_PA-729194.pdf8 pages
Itemised statement totalling $4850.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015602 | 2026-06-08 | Mesa Family Practice | $497.00 | 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.