CLM-2026-027047
Canyon Diagnostic Imaging, Radiology. Service 2026-09-03 at outpatient hospital (POS 22). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Christian Carter
- Member ID
- UHC-93847-10
- Date of birth
- 1964-06-17
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-416013
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1161
- Coverage period
- 2021-02-01 to 2026-04-23
- Deductible
- $2,073.58 of $2,500.0083%
- Out-of-pocket maximum
- $2,336.41 of $5,000.0047%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 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
- PA2025581545 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $235.00 | $129.25 | — | — | DeniedCO27 |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,066.00 | $1,136.30 | — | — | DeniedCO27 |
| Totals | $2,301.00 | $1,265.55 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-921792
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035195 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-03 is after coverage terminated on 2026-04-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025581545 on file for 70553. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (6871661313). | |
| 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: Canyon Diagnostic Imaging2026-09-03 11:36
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-29 03:57
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-29 12:16
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025581545_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-09-03 to 2026-12-02.
- Itemized billitemized_PA-921792.pdf3 pages
Itemised statement totalling $2301.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-03 is after coverage terminated on 2026-04-23.
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.