CLM-2026-030085
Desert Diagnostic Imaging, Radiology. Service 2026-01-06 at outpatient hospital (POS 22). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Dorothy Gonzalez
- Member ID
- UHC-11908-79
- Date of birth
- 1941-03-13
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-403639
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6514
- Coverage period
- 2024-01-01 to present
- Deductible
- $402.83 of $3,500.0012%
- Out-of-pocket maximum
- $5,158.33 of $14,000.0037%
- Copays
- office $25.00, 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
- 3515366425
- Network
- In network
- Rendering NPI
- 3515366425
- Location
- Phoenix, AZ · TIN 68-2801174
- Authorisation / referral
- PA2025088771 / 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 | $183.00 | $100.65 | $100.65 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $2,040.00 | $1,122.00 | $1,122.00 | $0.00 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | 25 | 1 | 1 | $583.00 | $320.65 | $320.65 | $0.00 | Paid |
| Totals | $2,806.00 | $1,543.30 | $1,543.30 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-617653
- 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-003726 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-01-06: SELECT-EPO (EPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025088771 on file for 70553. | |
| 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 Imaging2026-01-06 16:53
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025088771_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-01-06 to 2026-04-06.
- Itemized billitemized_PA-617653.pdf7 pages
Itemised statement totalling $2806.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024611 | 2026-06-16 | Sunrise Community Hospital | $1,731.00 | 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.