CLM-2026-029151
Desert Imaging Center, Radiology. Service 2026-03-03 at outpatient hospital (POS 22). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Gerald Cox
- Member ID
- UHC-87483-13
- Date of birth
- 1971-10-05
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-404903
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7872
- Coverage period
- 2024-03-01 to present
- Deductible
- $156.54 of $500.0031%
- Out-of-pocket maximum
- $588.69 of $2,000.0029%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7235030955
- Network
- In network
- Rendering NPI
- 7235030955
- Location
- San Diego, CA · TIN 44-8505123
- Authorisation / referral
- PA2026805367 / 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 | $233.00 | $128.15 | $128.15 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $220.00 | $121.00 | $121.00 | $0.00 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 2 | $2,456.00 | $1,350.80 | $471.26 | $879.54 | Paid |
| Totals | $2,909.00 | $1,599.95 | $720.41 | $879.54 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-243936
- 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-002479 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-03: NULL (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026805367 on file for 70553. | |
| Provider network | Pass | In-network provider Desert Imaging Center (7235030955). | |
| 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: Desert Imaging Center2026-03-03 11:07
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026805367_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-03-03 to 2026-06-01.
- Itemized billitemized_PA-243936.pdf7 pages
Itemised statement totalling $2909.00 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-2026-005560 | 2026-03-22 | Summit Internal Medicine Associates | $453.00 | Approved |
| CLM-2026-018168 | 2026-03-01 | Mesa Physical Therapy | $236.00 | Approved |
| CLM-2026-006346 | 2025-12-12 | Evergreen Family Practice | $259.00 | 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.