CLM-2026-024438
Canyon Diagnostic Imaging, Radiology. Service 2026-03-01 at outpatient hospital (POS 22). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Hannah Nguyen
- Member ID
- UHC-20168-56
- Date of birth
- 1972-05-08
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-403974
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2418
- Coverage period
- 2023-02-01 to present
- Deductible
- $1,186.02 of $2,500.0047%
- Out-of-pocket maximum
- $1,709.59 of $5,000.0034%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6871661313
- Network
- In network
- Rendering NPI
- 6871661313
- Location
- Tampa, FL · TIN 87-4174394
- Authorisation / referral
- PA2026671455 / REF915868
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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,021.00 | $1,111.55 | $1,111.55 | $0.00 | Paid |
| Totals | $2,021.00 | $1,111.55 | $1,111.55 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-188568
- 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-020470 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-01: CORE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026671455 on file for 70553. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (6871661313). | |
| 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: Canyon Diagnostic Imaging2026-03-01 17:27
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026671455_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-03-01 to 2026-05-30.
- Itemized billitemized_PA-188568.pdf7 pages
Itemised statement totalling $2021.00 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-2026-033347 | 2026-10-04 | Meadow Reference Lab | $60.00 | Needs review |
| CLM-2026-033346 | 2026-10-04 | Lakeside Reference Lab | $60.00 | Approved |
| CLM-2026-000004 | 2026-08-19 | Mesa Medical Group | $507.00 | 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.