CLM-2026-027142
Canyon Diagnostic Imaging, Radiology. Service 2026-05-03 at outpatient hospital (POS 22). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Brandon Peterson
- Member ID
- UHC-21678-78
- Date of birth
- 1965-06-28
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-430189
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1771
- Coverage period
- 2024-10-01 to present
- Deductible
- $879.98 of $1,500.0059%
- Out-of-pocket maximum
- $757.65 of $4,500.0017%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8055565153
- Network
- In network
- Rendering NPI
- 8055565153
- Location
- Atlanta, GA · TIN 44-7708549
- Authorisation / referral
- PA2026568761 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,664.00 | $915.20 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $1,978.00 | $1,087.90 | — | — | Review |
| Totals | $3,642.00 | $2,003.10 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-523607
- 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-026328 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-03: SELECT-EPO (EPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026568761 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (8055565153). | |
| Medical necessity | Review | CO50 | 74177, 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 Imaging2026-05-03 13:30
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026568761_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-05-03 to 2026-08-01.
- Itemized billitemized_PA-523607.pdf7 pages
Itemised statement totalling $3642.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 74177, 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001003 | 2026-05-10 | Riverside Bone and Joint Center | $7,573.00 | Approved |
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.