CLM-2026-029689
Evergreen Diagnostic Imaging, Radiology. Service 2026-06-01 at outpatient hospital (POS 22). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Mary Patel
- Member ID
- UHC-02629-56
- Date of birth
- 1985-08-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-423486
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3482
- Coverage period
- 2021-05-01 to present
- Deductible
- $122.70 of $1,000.0012%
- Out-of-pocket maximum
- $694.80 of $2,000.0035%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 4970897466
- Network
- In network
- Rendering NPI
- 4970897466
- Location
- Charlotte, NC · TIN 79-7771528
- Authorisation / referral
- PA2025465869 / REF750861
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 | $166.00 | $91.30 | $91.30 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $2,163.00 | $1,189.65 | $826.37 | $363.28 | Paid |
| Totals | $2,329.00 | $1,280.95 | $917.67 | $363.28 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-667991
- 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-004396 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-01: CORE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025465869 on file for 74177. | |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (4970897466). | |
| 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: Evergreen Diagnostic Imaging2026-06-01 11:46
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025465869_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-06-01 to 2026-08-30.
- Itemized billitemized_PA-667991.pdf2 pages
Itemised statement totalling $2329.00 across 2 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-2026-022485 | 2026-07-03 | Canyon Community Hospital | $2,847.00 | Needs review |
| CLM-2026-021659 | 2026-07-15 | Meadow Internal Medicine Associates | $3,004.00 | Needs review |
| CLM-2026-029690 | 2026-06-01 | Unity Diagnostic Imaging | $2,329.00 | 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.