CLM-2026-023001
Evergreen Diagnostic Imaging, Radiology. Service 2026-09-05 at outpatient hospital (POS 22). Received 2026-10-09.
Member
Resolved through the identity graph
- Member
- Deborah Johnston
- Member ID
- UHC-79873-39
- Date of birth
- 1963-05-04
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-428076
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4943
- Coverage period
- 2022-08-01 to present
- Deductible
- $422.65 of $500.0085%
- Out-of-pocket maximum
- $225.63 of $1,000.0023%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 7098075170
- Network
- In network
- Rendering NPI
- 7098075170
- Location
- Atlanta, GA · TIN 75-1814880
- Authorisation / referral
- PA2025396871 / REF280287
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 | $2,597.00 | $1,428.35 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $183.00 | $100.65 | — | — | Review |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $2,133.00 | $1,173.15 | — | — | Review |
| Totals | $4,913.00 | $2,702.15 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R51.9 Headache, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-594881
- 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-006457 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-05: NAVIGATE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025396871 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (7098075170). | |
| Medical necessity | Review | CO50 | 74177, 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: Evergreen Diagnostic Imaging2026-09-05 17:13
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 letterPA2025396871_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-09-05 to 2026-12-04.
- Itemized billitemized_PA-594881.pdf9 pages
Itemised statement totalling $4913.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 74177, 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.