CLM-2026-030209
Valley Imaging Center, Radiology. Service 2026-08-06 at outpatient hospital (POS 22). Received 2026-09-15.
Member
Resolved through the identity graph
- Member
- Diana McDonald
- Member ID
- UHC-97280-61
- Date of birth
- 2001-02-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400461
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1123
- Coverage period
- 2022-06-01 to present
- Deductible
- $102.70 of $500.0021%
- Out-of-pocket maximum
- $723.85 of $1,500.0048%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7696270280
- Network
- In network
- Rendering NPI
- 7696270280
- Location
- Scottsdale, AZ · TIN 61-0618370
- Authorisation / referral
- PA2025381361 / REF878609
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 | $1,278.00 | $702.90 | — | — | Review |
| Totals | $1,278.00 | $702.90 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-803514
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-043931 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-06: CORE-HMO (HMO), effective 2022-06-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025381361 on file for 74177. | |
| Provider network | Pass | In-network provider Valley Imaging Center (7696270280). | |
| 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 | Review | CO16 | Documentation incomplete: “Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Note ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Imaging Center2026-08-06 18:45
Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-15 01:21
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-15 11:45
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025381361_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-06 to 2026-11-04.
- Itemized billitemized_PA-803514.pdf3 pages
Itemised statement totalling $1278.00 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. Completeness: Documentation incomplete: “Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Note ”.
Other claims for this member
Same resolved identity
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
Development letter outstanding.