CLM-2026-025777
Desert Imaging Center, Radiology. Service 2026-01-24 at outpatient hospital (POS 22). Received 2026-02-18.
Member
Resolved through the identity graph
- Member
- Benjamin Johnson
- Member ID
- UHC-12502-35
- Date of birth
- 1989-06-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414767
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0171
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,123.58 of $1,500.0075%
- Out-of-pocket maximum
- $297.83 of $3,000.0010%
- Copays
- office $25.00, specialist $40.00, 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
- PA2025664512 / REF304113
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 | $479.00 | $263.45 | $263.45 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $147.00 | $80.85 | $80.85 | $0.00 | Paid |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 1 | $1,278.00 | $702.90 | $166.28 | $536.62 | Paid |
| Totals | $1,904.00 | $1,047.20 | $510.58 | $536.62 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-205263
- 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-014124 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-24: NAVIGATE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025664512 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 Center2026-01-24 11:35
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025664512_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-01-24 to 2026-04-24.
- Itemized billitemized_PA-205263.pdf2 pages
Itemised statement totalling $1904.00 across 3 lines.
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.