CLM-2026-029438
Desert Diagnostic Imaging, Radiology. Service 2026-05-05 at outpatient hospital (POS 22). Received 2026-05-21.
Member
Resolved through the identity graph
- Member
- Luis Martin
- Member ID
- UHC-11583-17
- Date of birth
- 1977-08-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418660
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9769
- Coverage period
- 2025-03-01 to present
- Deductible
- $301.64 of $1,500.0020%
- Out-of-pocket maximum
- $1,559.76 of $4,500.0035%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 2571625872
- Network
- In network
- Rendering NPI
- 2571625872
- Location
- Dallas, TX · TIN 43-0454627
- Authorisation / referral
- PA2026286367 / 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 | $206.00 | $113.30 | $113.30 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $397.00 | $218.35 | $218.35 | $0.00 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $2,163.00 | $1,189.65 | $963.59 | $226.06 | Paid |
| Totals | $2,766.00 | $1,521.30 | $1,295.24 | $226.06 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-969215
- 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-004701 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-05: OPTIONS-PPO (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026286367 on file for 70553. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (2571625872). | |
| 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 Diagnostic Imaging2026-05-05 11:27
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026286367_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-05-05 to 2026-08-03.
- Itemized billitemized_PA-969215.pdf5 pages
Itemised statement totalling $2766.00 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
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.