CLM-2026-028277
Northgate Imaging Center, Radiology. Service 2025-12-19 at outpatient hospital (POS 22). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Gary Matthews
- Member ID
- none on golden record
- Date of birth
- 1945-11-13
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-431401
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-1709
- Coverage period
- 2023-03-01 to present
- Deductible
- $245.98 of $500.0049%
- Out-of-pocket maximum
- $338.26 of $1,000.0034%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3050464585
- Network
- Out of network
- Rendering NPI
- 3050464585
- Location
- San Diego, CA · TIN 61-2250278
- Authorisation / referral
- PA2026387144 / 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 | $1,935.00 | $870.75 | — | — | Review |
| Totals | $1,935.00 | $870.75 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-915572
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002551 (verified, link confidence 0.93). | |
| Eligibility | Note | Active on 2025-12-19: MEDICARE-ADV-B (MA), effective 2023-03-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| 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 PA2026387144 on file for 74177. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for chest pain, unspecified. Plan discussed, medications reconciled. Note dictat”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Imaging Center2025-12-19 09:32
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-08 06:14
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Prior auth letterPA2026387144_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-12-19 to 2026-03-19.
- Itemized billitemized_PA-915572.pdf5 pages
Itemised statement totalling $1935.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Eligibility: Active on 2025-12-19: MEDICARE-ADV-B (MA), effective 2023-03-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Follow-up for chest pain, unspecified. Plan discussed, medications reconciled. Note dictat”.
- AI recommendationPended2026-10-21 14:15The claim is for a CT abdomen and pelvis with contrast, billed by an out-of-network provider. The claim has passed most checks, including prior authorization and medical necessity. However, the clinical documentation is incomplete as the rendering provider's signature is missing on the clinical note [N1], [N2]. This requires confirmation before the claim can be adjudicated. The billed amount is below the auto-adjudication ceiling, and the claim is within the timely filing limit. The member is eligible for the service under their coverage. The provider is out-of-network, but the service is authorized and medically necessary. The claim requires human sign-off due to the high billed amount [C].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 90a76461
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim is for a CT abdomen and pelvis with contrast, billed by an out-of-network provider. The claim has passed most checks, including prior authorization and medical necessity. However, the clinical documentation is incomplete as the rendering provider's signature is missing on the clinical note [N1], [N2]. This requires confirmation before the claim can be adjudicated. The billed amount is below the auto-adjudication ceiling, and the claim is within the timely filing limit. The member is eligible for the service under their coverage. The provider is out-of-network, but the service is authorized and medically necessary. The claim requires human sign-off due to the high billed amount [C].
- Confirm the rendering provider's signature on the clinical note.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO16 Claim lacks information needed for adjudication
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.