CLM-2026-026454
Mesa Imaging Center, Radiology. Service 2026-08-06 at outpatient hospital (POS 22). Received 2026-08-09.
Member
Resolved through the identity graph
- Member
- Aisha Davis
- Member ID
- UHC-31947-84
- Date of birth
- 2006-03-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408175
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6238
- Coverage period
- 2025-12-01 to present
- Deductible
- $31.96 of $500.006%
- Out-of-pocket maximum
- $453.40 of $1,500.0030%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 6656135814
- Network
- Out of network
- Rendering NPI
- 6656135814
- Location
- Minneapolis, MN · TIN 75-3868074
- Authorisation / referral
- PA2026232857 / REF563817
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 | $403.00 | $181.35 | — | — | DeniedCO204 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 2 | $1,801.00 | $810.45 | — | — | DeniedCO204 |
| Totals | $2,204.00 | $991.80 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-804378
- 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-017031 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-06: CORE-HMO (HMO), effective 2025-12-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026232857 on file for 74177. | |
| Provider network | Fail | CO204 | Billing provider 6656135814 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Mesa Imaging Center2026-08-06 14:52
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-09 01:24
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2026232857_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-08-06 to 2026-11-04.
- Itemized billitemized_PA-804378.pdf3 pages
Itemised statement totalling $2204.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 6656135814 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.