CLM-2026-024767
Summit Diagnostic Imaging, Radiology. Service 2026-06-07 at outpatient hospital (POS 22). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Daniel Weaver
- Member ID
- none on golden record
- Date of birth
- 1967-11-08
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422629
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Eligibility
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
- PA2026601246 / 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $366.00 | $201.30 | — | — | PendedN30 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 1,2 | $2,323.00 | $1,277.65 | — | — | PendedN30 |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $158.00 | $86.90 | — | — | PendedN30 |
| Totals | $2,847.00 | $1,565.85 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-308880
- 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-035572 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026601246 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 Imaging2026-06-07 17:12
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026601246_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-06-07 to 2026-09-05.
- Itemized billitemized_PA-308880.pdf3 pages
Itemised statement totalling $2847.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.