CLM-2026-029535
Desert Diagnostic Imaging, Radiology. Service 2026-10-07 at outpatient hospital (POS 22). Received 2026-10-15.
Member
Resolved through the identity graph
- Member
- Jordan Gardner
- Member ID
- UHC-58120-60
- Date of birth
- 1969-10-17
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-403025
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3513
- Coverage period
- 2022-03-01 to present
- Deductible
- $681.42 of $1,500.0045%
- Out-of-pocket maximum
- $1,288.10 of $3,000.0043%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 19 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
- PA2025418011 / REF102745
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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,355.00 | $1,295.25 | — | — | Review |
| Totals | $2,355.00 | $1,295.25 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-114346
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023374 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-07: NAVIGATE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025418011 on file for 74177. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (2571625872). | |
| Medical necessity | Review | CO50 | 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Imaging2026-10-07 10:28
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025418011_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-10-07 to 2027-01-05.
- Itemized billitemized_PA-114346.pdf7 pages
Itemised statement totalling $2355.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019589 | 2026-04-04 | Mesa Clinical Laboratories | $79.00 | Approved |
| CLM-2026-001837 | 2026-02-24 | Unity Community Hospital | $1,823.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.