CLM-2026-025776
Desert Imaging Center, Radiology. Service 2026-03-22 at outpatient hospital (POS 22). Received 2026-04-30.
Member
Resolved through the identity graph
- Member
- Stephen Morrison
- Member ID
- UHC-09325-93
- Date of birth
- 1999-05-03
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-426274
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9758
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,226.24 of $1,500.0082%
- Out-of-pocket maximum
- $1,279.20 of $3,000.0043%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7235030955
- Network
- In network
- Rendering NPI
- 7235030955
- Location
- San Diego, CA · TIN 44-8505123
- Authorisation / referral
- PA2025762835 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $452.00 | $248.60 | — | — | DeniedCO18 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $1,739.00 | $956.45 | — | — | DeniedCO18 |
| Totals | $2,191.00 | $1,205.05 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-259867
- 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-028005 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-22: SELECT-EPO (EPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-025775: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | Authorisation PA2025762835 on file for 74177. | |
| Provider network | Pass | In-network provider Desert Imaging Center (7235030955). | |
| 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 Imaging Center2026-03-22 18:13
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-30 01:02
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Prior auth letterPA2025762835_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-03-22 to 2026-06-20.
- Itemized billitemized_PA-259867.pdf4 pages
Itemised statement totalling $2191.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-025775: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025775 | 2026-03-22 | Desert Imaging Center | $2,191.00 | 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
Exact duplicate of an earlier submission.