CLM-2026-027441
Desert Diagnostic Imaging, Radiology. Service 2026-01-26 at outpatient hospital (POS 22). Received 2026-02-15.
Member
Resolved through the identity graph
- Member
- Megan Park
- Member ID
- UHC-97248-72
- Date of birth
- 1948-12-04
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-422108
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2902
- Coverage period
- 2023-04-01 to present
- Deductible
- $745.86 of $1,500.0050%
- Out-of-pocket maximum
- $1,497.05 of $4,500.0033%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 2571625872
- Network
- In network
- Rendering NPI
- 2571625872
- Location
- Dallas, TX · TIN 43-0454627
- Authorisation / referral
- none / 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 | $2,048.00 | $1,126.40 | — | — | DeniedCO197 |
| Totals | $2,048.00 | $1,126.40 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-197036
- 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-005256 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-26: MEDICARE-ADV-B (MA), effective 2023-04-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (2571625872). | |
| 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: Desert Diagnostic Imaging2026-01-26 13:00
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-15 03:47
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-15 14:33
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-197036.pdf2 pages
Itemised statement totalling $2048.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 74177 require precertification; no authorisation number on the claim.
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
Precertification required and absent.