CLM-2026-023872
Summit Diagnostic Imaging, Radiology. Service 2026-02-26 at outpatient hospital (POS 22). Received 2026-03-12.
Member
Resolved through the identity graph
- Member
- Joshua Simmons
- Member ID
- UHC-19558-30
- Date of birth
- 1974-12-28
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-415812
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9345
- Coverage period
- 2025-05-01 to present
- Deductible
- $372.03 of $500.0074%
- Out-of-pocket maximum
- $865.76 of $2,000.0043%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 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
- PA2026569300 / 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 | $2,340.00 | $1,287.00 | $475.68 | $811.32 | Paid |
| Totals | $2,340.00 | $1,287.00 | $475.68 | $811.32 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-388832
- 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-005284 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-26: CHOICE-PLUS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026569300 on file for 74177. | |
| 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 Imaging2026-02-26 12:38
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026569300_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-02-26 to 2026-05-27.
- Itemized billitemized_PA-388832.pdf9 pages
Itemised statement totalling $2340.00 across 1 line.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033602 | 2026-05-02 | Mesa Clinical Laboratories | $38.00 | Approved |
| CLM-2026-016034 | 2026-04-15 | Mesa Internal Medicine Associates | $625.00 | Needs review |
| CLM-2026-026642 | 2026-02-01 | Harbor Medical Group | $3,563.00 | Needs review |
| CLM-2026-024340 | 2025-12-13 | Summit Clinical Laboratories | $143.00 | 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.