CLM-2026-025799
Canyon Diagnostic Imaging, Radiology. Service 2026-02-20 at outpatient hospital (POS 22). Received 2026-03-13.
Member
Resolved through the identity graph
- Member
- Jonathan Gonzales
- Member ID
- UHC-10277-83
- Date of birth
- 2008-06-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417078
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group N/A
- Coverage period
- 2022-09-01 to present
- Deductible
- $384.80 of $500.0077%
- Out-of-pocket maximum
- $95.41 of $1,000.0010%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6871661313
- Network
- In network
- Rendering NPI
- 6871661313
- Location
- Tampa, FL · TIN 87-4174394
- Authorisation / referral
- PA2025903089 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $1,895.00 | $1,042.25 | — | — | Review |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $434.00 | $238.70 | — | — | Review |
| Totals | $2,329.00 | $1,280.95 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-495045
- 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-017163 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-20: MEDICARE-ADV-B (MA), effective 2022-09-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025903089 on file for 70553. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (6871661313). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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: Canyon Diagnostic Imaging2026-02-20 12:49
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025903089_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-02-20 to 2026-05-21.
- Itemized billitemized_PA-495045.pdf6 pages
Itemised statement totalling $2329.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
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.