CLM-2026-024241
Riverside Diagnostic Imaging, Radiology. Service 2026-08-03 at outpatient hospital (POS 22). Received 2026-08-13.
Member
Resolved through the identity graph
- Member
- Sofia Jimenez
- Member ID
- UHC-48462-32
- Date of birth
- 2000-07-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-403440
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group -
- Coverage period
- 2022-09-01 to 2026-07-01
- Deductible
- $169.02 of $500.0034%
- Out-of-pocket maximum
- $327.97 of $1,000.0033%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6802768252
- Network
- In network
- Rendering NPI
- 6802768252
- Location
- Scottsdale, AZ · TIN 85-0998777
- Authorisation / referral
- none / 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 | $137.00 | $75.35 | — | — | DeniedCO27 |
| Totals | $137.00 | $75.35 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-132110
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025952 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-03 is after coverage terminated on 2026-07-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Diagnostic Imaging (6802768252). | |
| 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: Riverside Diagnostic Imaging2026-08-03 15:48
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-13 06:38
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-13 17:52
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-132110.pdf4 pages
Itemised statement totalling $137.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-03 is after coverage terminated on 2026-07-01.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005275 | 2026-03-24 | Meadow Diagnostic Imaging | $2,870.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.