CLM-2026-029741
Evergreen Diagnostic Imaging, Radiology. Service 2026-04-03 at outpatient hospital (POS 22). Received 2026-04-29.
Member
Resolved through the identity graph
- Member
- Jordan Garcia
- Member ID
- UHC-92335-51
- Date of birth
- 1983-04-26
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-406508
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9315
- Coverage period
- 2021-11-01 to 2026-03-24
- Deductible
- $1,318.43 of $1,500.0088%
- Out-of-pocket maximum
- $1,362.85 of $4,500.0030%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 16 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
- PA2025998705 / REF213641
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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,444.00 | $1,894.20 | — | — | DeniedCO27 |
| Totals | $3,444.00 | $1,894.20 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-338734
- 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-010350 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-03 is after coverage terminated on 2026-03-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025998705 on file for 70553. | |
| 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 Imaging2026-04-03 17:26
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-04-29 03:17
Attachments
Documents received with the claim
- Prior auth letterPA2025998705_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-03 to 2026-07-02.
- Itemized billitemized_PA-338734.pdf3 pages
Itemised statement totalling $3444.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-03 is after coverage terminated on 2026-03-24.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028929 | 2026-03-24 | Northgate Cardiovascular Associates | $10,063.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.