CLM-2026-029696
Desert Diagnostic Imaging, Radiology. Service 2026-05-27 at outpatient hospital (POS 22). Received 2026-07-06.
Member
Resolved through the identity graph
- Member
- Nathan Gutierrez
- Member ID
- UHC-89336-04
- Date of birth
- 1953-07-17
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-427004
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6600
- Coverage period
- 2025-10-01 to present
- Deductible
- $869.10 of $1,000.0087%
- Out-of-pocket maximum
- $787.48 of $3,000.0026%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3515366425
- Network
- In network
- Rendering NPI
- 3515366425
- Location
- Phoenix, AZ · TIN 68-2801174
- Authorisation / referral
- none / 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 | $355.00 | $195.25 | $143.77 | $51.48 | Paid |
| Totals | $355.00 | $195.25 | $143.77 | $51.48 | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-284619
- 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-037495 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-27: SELECT-EPO (EPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (3515366425). | |
| 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 Imaging2026-05-27 10:06
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Itemized billitemized_PA-284619.pdf9 pages
Itemised statement totalling $355.00 across 1 line.
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
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.