CLM-2026-024122
Valley Imaging Center, Radiology. Service 2026-05-18 at outpatient hospital (POS 22). Received 2026-06-15.
Member
Resolved through the identity graph
- Member
- Aisha Hughes
- Member ID
- UHC-26837-69
- Date of birth
- 2000-08-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-421406
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3148
- Coverage period
- 2024-10-01 to present
- Deductible
- $894.07 of $1,000.0089%
- Out-of-pocket maximum
- $1,802.30 of $4,000.0045%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 5964910181
- Network
- In network
- Rendering NPI
- 5964910181
- Location
- Austin, TX · TIN 60-0192260
- Authorisation / referral
- PA2025698418 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $210.00 | $115.50 | $106.89 | $8.61 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,292.00 | $710.60 | $71.06 | $639.54 | Paid |
| Totals | $1,502.00 | $826.10 | $177.95 | $648.15 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. M25.561 Pain in right knee
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-188572
- 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-006732 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-18: MEDICARE-ADV-A (MA), effective 2024-10-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025698418 on file for 74177. | |
| Provider network | Pass | In-network provider Valley Imaging Center (5964910181). | |
| 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 Center2026-05-18 17:58
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025698418_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-05-18 to 2026-08-16.
- Itemized billitemized_PA-188572.pdf5 pages
Itemised statement totalling $1502.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024746 | 2026-09-07 | Harbor Imaging Center | $3,525.00 | Needs review |
| CLM-2026-026796 | 2026-05-05 | Evergreen Reference Lab | $50.00 | Approved |
| CLM-2026-026643 | 2026-05-22 | Canyon Reference Lab | $145.00 | 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.