CLM-2026-030482
Northgate Imaging Center, Radiology. Service 2026-07-05 at outpatient hospital (POS 22). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Deny Parker
- Member ID
- UHC-00717-49
- Date of birth
- 1972-05-03
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417500
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8205
- Coverage period
- 2024-12-01 to present
- Deductible
- $208.67 of $500.0042%
- Out-of-pocket maximum
- $395.59 of $1,500.0026%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3050464585
- Network
- Out of network
- Rendering NPI
- 3050464585
- Location
- San Diego, CA · TIN 61-2250278
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $197.00 | $88.65 | — | — | Review |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $306.00 | $137.70 | — | — | Review |
| Totals | $503.00 | $226.35 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-295718
- 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-003258 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-05: N/A (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 3 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals”. 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: Northgate Imaging Center2026-07-05 15:27
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-08 04:08
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-295718.pdf3 pages
Itemised statement totalling $503.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals”.
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.