CLM-2026-028919
Cornerstone Imaging Center, Radiology. Service 2025-12-23 at outpatient hospital (POS 22). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Hannah Nguyen
- Member ID
- UHC-03763-39
- Date of birth
- 1950-03-16
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-407958
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3911
- Coverage period
- 2025-02-01 to present
- Deductible
- $1,115.61 of $1,500.0074%
- Out-of-pocket maximum
- $1,406.85 of $4,500.0031%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9835477198
- Network
- In network
- Rendering NPI
- 9835477198
- Location
- Tampa, FL · TIN 89-9420622
- Authorisation / referral
- PA2026901915 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $192.00 | $105.60 | $105.60 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,029.00 | $1,115.95 | $446.22 | $669.73 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 1 | $2,288.00 | $1,258.40 | $251.68 | $1,006.72 | Paid |
| Totals | $4,509.00 | $2,479.95 | $803.50 | $1,676.45 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-187770
- 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-002060 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-23: OPTIONS-PPO (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026901915 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Cornerstone Imaging Center (9835477198). | |
| 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: Cornerstone Imaging Center2025-12-23 12:17
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026901915_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2025-12-23 to 2026-03-23.
- Itemized billitemized_PA-187770.pdf4 pages
Itemised statement totalling $4509.00 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-2026-022938 | 2025-12-02 | Canyon Reference Lab | $143.00 | Approved |
| CLM-2026-017717 | 2025-11-23 | Heritage GI Associates | $324.00 | 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.