CLM-2026-025302
Northgate Imaging Center, Radiology. Service 2026-09-09 at outpatient hospital (POS 22). Received 2026-10-13.
Member
Resolved through the identity graph
- Member
- Helen Singh
- Member ID
- UHC-90545-25
- Date of birth
- 1928-05-11
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-400530
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1950
- Coverage period
- 2021-06-01 to present
- Deductible
- $28.70 of $3,500.001%
- Out-of-pocket maximum
- $1,701.88 of $7,000.0024%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3050464585
- Network
- Out of network
- Rendering NPI
- 3050464585
- Location
- San Diego, CA · TIN 61-2250278
- Authorisation / referral
- none / REF898627
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 | $119.00 | $53.55 | — | — | DeniedCO204 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $380.00 | $171.00 | — | — | DeniedCO204 |
| Totals | $499.00 | $224.55 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-930807
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008075 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-09: CORE-HMO (HMO), effective 2021-06-01. | |
| Timely filing | Pass | Received 34 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 | Fail | CO204 | Billing provider 3050464585 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Northgate Imaging Center2026-09-09 09:35
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-13 04:27
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-930807.pdf3 pages
Itemised statement totalling $499.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 3050464585 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030246 | 2026-03-24 | Valley Internal Medicine Associates | $216.00 | 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
No out-of-network benefit on this plan.