CLM-2026-024653
Valley Imaging Center, Radiology. Service 2026-09-17 at outpatient hospital (POS 22). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Keith Jones
- Member ID
- UHC-95396-91
- Date of birth
- 1987-02-19
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-414992
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8730
- Coverage period
- 2023-10-01 to present
- Deductible
- $360.40 of $2,500.0014%
- Out-of-pocket maximum
- $1,592.79 of $7,500.0021%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 15 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
- PA2026102646 / 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 | $160.00 | $88.00 | $88.00 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $1,799.00 | $989.45 | $989.45 | $0.00 | Paid |
| Totals | $1,959.00 | $1,077.45 | $1,077.45 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-647220
- 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-020699 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-17: MEDICARE-ADV-A (MA), effective 2023-10-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026102646 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 Center2026-09-17 11:51
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026102646_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-09-17 to 2026-12-16.
- Itemized billitemized_PA-647220.pdf5 pages
Itemised statement totalling $1959.00 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-2026-011455 | 2026-04-20 | Heritage Medical Group | $12.00 | Approved |
| CLM-2026-025999 | 2026-04-05 | Evergreen Dermatology Clinic | $815.00 | Approved |
| CLM-2026-007414 | 2026-02-22 | Evergreen Medical Group | $279.00 | 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.