CLM-2026-026684
Summit Imaging Center, Radiology. Service 2026-08-03 at outpatient hospital (POS 22). Received 2026-08-10.
Member
Resolved through the identity graph
- Member
- Larry Reid
- Member ID
- UHC-25768-96
- Date of birth
- 1955-09-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-404800
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2284
- Coverage period
- 2024-05-01 to 2026-06-09
- Deductible
- $108.73 of $1,000.0011%
- Out-of-pocket maximum
- $481.88 of $4,000.0012%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4562878908
- Network
- In network
- Rendering NPI
- 4562878908
- Location
- Minneapolis, MN · TIN 57-8653616
- Authorisation / referral
- PA2025743482 / REF326759
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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,372.00 | $1,304.60 | — | — | DeniedCO27 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $403.00 | $221.65 | — | — | DeniedCO27 |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $129.00 | $70.95 | — | — | DeniedCO27 |
| Totals | $2,904.00 | $1,597.20 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-779854
- 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-007296 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-03 is after coverage terminated on 2026-06-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025743482 on file for 74177. | |
| Provider network | Pass | In-network provider Summit Imaging Center (4562878908). | |
| 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: Summit Imaging Center2026-08-03 17:32
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-10 05:13
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-10 16:48
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025743482_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-03 to 2026-11-01.
- Itemized billitemized_PA-779854.pdf9 pages
Itemised statement totalling $2904.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-03 is after coverage terminated on 2026-06-09.
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
Service after coverage termination.