CLM-2026-028666
Valley Imaging Center, Radiology. Service 2026-07-12 at outpatient hospital (POS 22). Received 2026-08-24.
Member
Resolved through the identity graph
- Member
- Christian Porter
- Member ID
- UHC-10085-76
- Date of birth
- 1976-04-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407675
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3011
- Coverage period
- 2021-08-01 to present
- Deductible
- $821.21 of $1,000.0082%
- Out-of-pocket maximum
- $706.54 of $4,000.0018%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7696270280
- Network
- In network
- Rendering NPI
- 7696270280
- Location
- Scottsdale, AZ · TIN 61-0618370
- Authorisation / referral
- PA2026142963 / 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $252.00 | $138.60 | — | — | PendedIDQ |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 1 | $3,267.00 | $1,796.85 | — | — | PendedIDQ |
| Totals | $3,519.00 | $1,935.45 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-872622
- 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 | Fail | IDQ | Member record is in open steward case CASE-003261; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-07-12: OPTIONS-PPO (PPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026142963 on file for 70553. | |
| Provider network | Pass | In-network provider Valley Imaging Center (7696270280). | |
| 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: Valley Imaging Center2026-07-12 16:39
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026142963_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-07-12 to 2026-10-10.
- Itemized billitemized_PA-872622.pdf9 pages
Itemised statement totalling $3519.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-003261; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
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.