CLM-2026-023372
Valley Imaging Center, Radiology. Service 2025-11-29 at outpatient hospital (POS 22). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Joyce Palmer
- Member ID
- UHC-68741-60
- Date of birth
- 1980-11-24
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-406301
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8760
- Coverage period
- 2025-10-01 to present
- Deductible
- $794.71 of $3,500.0023%
- Out-of-pocket maximum
- $1,455.16 of $7,000.0021%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7696270280
- Network
- In network
- Rendering NPI
- 7696270280
- Location
- Scottsdale, AZ · TIN 61-0618370
- Authorisation / referral
- PA2025366557 / REF211113
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 | $420.00 | $231.00 | $231.00 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $2,962.00 | $1,629.10 | $1,629.10 | $0.00 | Paid |
| Totals | $3,382.00 | $1,860.10 | $1,860.10 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-718205
- 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-003453 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-11-29: NAVIGATE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025366557 on file for 70553. | |
| Provider network | Pass | In-network provider Valley Imaging Center (7696270280). | |
| 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: Valley Imaging Center2025-11-29 12:04
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Prior auth letterPA2025366557_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2025-11-29 to 2026-02-27.
- Itemized billitemized_PA-718205.pdf6 pages
Itemised statement totalling $3382.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005132 | 2026-05-31 | Canyon Clinical Laboratories | $65.00 | Approved |
| CLM-2026-021808 | 2025-12-27 | Meadow Dermatology Clinic | $472.00 | 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.