CLM-2026-028705
Valley Imaging Center, Radiology. Service 2026-07-09 at outpatient hospital (POS 22). Received 2026-08-01.
Member
Resolved through the identity graph
- Member
- Nancy George
- Member ID
- UHC-95306-31
- Date of birth
- 1979-06-04
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420240
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5615
- Coverage period
- 2022-06-01 to present
- Deductible
- $12.71 of $1,500.001%
- Out-of-pocket maximum
- $417.43 of $3,000.0014%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 5964910181
- Network
- In network
- Rendering NPI
- 5964910181
- Location
- Austin, TX · TIN 60-0192260
- Authorisation / referral
- PA2026059323 / REF986468
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 | $1,419.00 | $780.45 | $780.45 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $381.00 | $209.55 | $209.55 | $0.00 | Paid |
| Totals | $1,800.00 | $990.00 | $990.00 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-110335
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014018 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-09: CORE-HMO (HMO), effective 2022-06-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026059323 on file for 74177. | |
| Provider network | Pass | In-network provider Valley Imaging Center (5964910181). | |
| 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 Center2026-07-09 12:19
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026059323_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-07-09 to 2026-10-07.
- Itemized billitemized_PA-110335.pdf7 pages
Itemised statement totalling $1800.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012163 | 2026-08-30 | Desert Internal Medicine Associates | $149.00 | Approved |
| CLM-2026-028706 | 2026-07-09 | Valley Imaging Center | $1,800.00 | Needs review |
| CLM-2026-015563 | 2026-05-22 | Desert Imaging Center | $2,416.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.