CLM-2026-031471
Harbor Imaging Center, Radiology. Service 2026-08-17 at outpatient hospital (POS 22). Received 2026-08-28.
Member
Resolved through the identity graph
- Member
- Elizabeth Matthews
- Member ID
- UHC-83163-59
- Date of birth
- 1994-08-26
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431356
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-1266
- Coverage period
- 2023-02-01 to present
- Deductible
- $296.18 of $2,500.0012%
- Out-of-pocket maximum
- $1,740.08 of $7,500.0023%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3423421452
- Network
- In network
- Rendering NPI
- 3423421452
- Location
- Denver, CO · TIN 47-9293451
- 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,665.00 | $915.75 | — | — | DeniedCO197 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $371.00 | $204.05 | — | — | DeniedCO197 |
| Totals | $2,036.00 | $1,119.80 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-979376
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008094 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-17: N/A (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Harbor Imaging Center (3423421452). | |
| 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: Harbor Imaging Center2026-08-17 18:30
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-28 06:26
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-28 12:59
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-979376.pdf9 pages
Itemised statement totalling $2036.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 74177 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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
Precertification required and absent.