CLM-2026-025945
Valley Imaging Center, Radiology. Service 2026-05-10 at outpatient hospital (POS 22). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Martha Salazar
- Member ID
- UHC-04503-85
- Date of birth
- 1982-06-10
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-420533
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4450
- Coverage period
- 2023-03-01 to present
- Deductible
- $2,039.21 of $2,500.0082%
- Out-of-pocket maximum
- $2,178.07 of $7,500.0029%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7696270280
- Network
- In network
- Rendering NPI
- 7696270280
- Location
- Scottsdale, AZ · TIN 61-0618370
- Authorisation / referral
- none / REF334397
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 | $181.00 | $99.55 | $99.55 | $0.00 | Paid |
| Totals | $181.00 | $99.55 | $99.55 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-439538
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015358 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-10: CORE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 23 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 Valley Imaging Center (7696270280). | |
| 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: Valley Imaging Center2026-05-10 12:11
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Itemized billitemized_PA-439538.pdf5 pages
Itemised statement totalling $181.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean 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.