CLM-2026-028931
Riverside Diagnostic Imaging, Radiology. Service 2026-02-09 at outpatient hospital (POS 22). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Elijah Allen
- Member ID
- UHC-15522-20
- Date of birth
- 1943-12-01
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-408153
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3627
- Coverage period
- 2021-12-01 to present
- Deductible
- $1,673.81 of $2,500.0067%
- Out-of-pocket maximum
- $3,004.96 of $7,500.0040%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6802768252
- Network
- In network
- Rendering NPI
- 6802768252
- Location
- Scottsdale, AZ · TIN 85-0998777
- Authorisation / referral
- PA2026428402 / 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 | $124.00 | $68.20 | $68.20 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,352.00 | $1,293.60 | $918.67 | $374.93 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $531.00 | $292.05 | $87.62 | $204.43 | Paid |
| Totals | $3,007.00 | $1,653.85 | $1,074.49 | $579.36 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-213666
- 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-018217 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-09: - (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026428402 on file for 70553. | |
| Provider network | Pass | In-network provider Riverside Diagnostic Imaging (6802768252). | |
| 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: Riverside Diagnostic Imaging2026-02-09 14:05
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026428402_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-02-09 to 2026-05-10.
- Itemized billitemized_PA-213666.pdf4 pages
Itemised statement totalling $3007.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010182 | 2026-01-10 | Northgate Internal Medicine Associates | $287.00 | Denied |
| CLM-2026-022599 | 2026-07-05 | Riverside Orthopedic Specialists | $36,204.00 | Needs review |
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.