CLM-2026-028882
Harbor Imaging Center, Radiology. Service 2026-08-05 at outpatient hospital (POS 22). Received 2026-09-03.
Member
Resolved through the identity graph
- Member
- Douglas Banks
- Member ID
- UHC-51125-18
- Date of birth
- 1982-01-06
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-429700
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2284
- Coverage period
- 2023-05-01 to present
- Deductible
- $2,132.60 of $2,500.0085%
- Out-of-pocket maximum
- $1,732.58 of $7,500.0023%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3423421452
- Network
- In network
- Rendering NPI
- 3423421452
- Location
- Denver, CO · TIN 47-9293451
- Authorisation / referral
- PA2025953612 / 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 | $268.00 | $147.40 | $147.40 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $195.00 | $107.25 | $107.25 | $0.00 | Paid |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,364.00 | $750.20 | $303.99 | $446.21 | Paid |
| Totals | $1,827.00 | $1,004.85 | $558.64 | $446.21 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-525446
- 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-008629 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-08-05: CHOICE-PLUS-PPO (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025953612 on file for 74177. | |
| Provider network | Pass | In-network provider Harbor Imaging Center (3423421452). | |
| 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: Harbor Imaging Center2026-08-05 13:43
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025953612_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-08-05 to 2026-11-03.
- Itemized billitemized_PA-525446.pdf7 pages
Itemised statement totalling $1827.00 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-2026-026689 | 2026-09-02 | Northgate Cardiovascular Associates | $595.00 | Approved |
| CLM-2026-003202 | 2026-01-16 | Canyon Reference Lab | $174.00 | 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.