CLM-2026-025677
Desert Diagnostic Imaging, Radiology. Service 2025-12-12 at outpatient hospital (POS 22). Received 2026-01-14.
Member
Resolved through the identity graph
- Member
- Janice Alexander
- Member ID
- UHC-43589-03
- Date of birth
- 2008-05-23
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-406751
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group N/A
- Coverage period
- 2021-12-01 to present
- Deductible
- $208.08 of $500.0042%
- Out-of-pocket maximum
- $914.51 of $2,000.0046%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3515366425
- Network
- In network
- Rendering NPI
- 3515366425
- Location
- Phoenix, AZ · TIN 68-2801174
- Authorisation / referral
- none / REF497324
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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $597.00 | $328.35 | $295.56 | $32.79 | Paid |
| Totals | $597.00 | $328.35 | $295.56 | $32.79 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-416880
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004306 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-12: CORE-HMO (HMO), effective 2021-12-01. | |
| Timely filing | Pass | Received 33 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 Desert Diagnostic Imaging (3515366425). | |
| 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: Desert Diagnostic Imaging2025-12-12 18:23
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-416880.pdf2 pages
Itemised statement totalling $597.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.