CLM-2026-028855
Canyon Diagnostic Imaging, Radiology. Service 2026-01-05 at outpatient hospital (POS 22). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Patricia Knight
- Member ID
- UHC-45826-06
- Date of birth
- 2007-09-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-402006
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2281
- Coverage period
- 2023-07-01 to present
- Deductible
- $696.08 of $2,500.0028%
- Out-of-pocket maximum
- $1,104.16 of $7,500.0015%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1352145704
- Network
- In network
- Rendering NPI
- 1352145704
- Location
- Atlanta, GA · TIN 24-1782323
- Authorisation / referral
- PA2026838674 / 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 | $2,417.00 | $1,329.35 | $1,329.35 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $131.00 | $72.05 | $72.05 | $0.00 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $596.00 | $327.80 | $327.80 | $0.00 | Paid |
| Totals | $3,144.00 | $1,729.20 | $1,729.20 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R51.9 Headache, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-345768
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003762 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-05: SELECT-EPO (EPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026838674 on file for 74177. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (1352145704). | |
| 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: Canyon Diagnostic Imaging2026-01-05 11:38
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026838674_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-01-05 to 2026-04-05.
- Itemized billitemized_PA-345768.pdf3 pages
Itemised statement totalling $3144.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027872 | 2026-07-05 | Lakeside Medical Group | $175.00 | 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.