CLM-2026-031521
Desert Diagnostic Imaging, Radiology. Service 2026-03-05 at outpatient hospital (POS 22). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Robert Wang
- Member ID
- UHC-24041-45
- Date of birth
- 1951-08-03
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-404044
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1677
- Coverage period
- 2025-08-01 to present
- Deductible
- $322.88 of $500.0065%
- Out-of-pocket maximum
- $58.26 of $1,500.004%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 2571625872
- Network
- In network
- Rendering NPI
- 2571625872
- Location
- Dallas, TX · TIN 43-0454627
- Authorisation / referral
- PA2025771291 / 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 | $223.00 | $122.65 | $122.65 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $3,161.00 | $1,738.55 | $391.29 | $1,347.26 | Paid |
| 3 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1,2 | $256.00 | $140.80 | $28.16 | $112.64 | Paid |
| Totals | $3,640.00 | $2,002.00 | $542.10 | $1,459.90 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-707979
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018082 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-05: MEDICARE-ADV-B (MA), effective 2025-08-01. | |
| Timely filing | Pass | Received 2 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025771291 on file for 70553. | |
| Provider network | Pass | In-network provider Desert Diagnostic Imaging (2571625872). | |
| 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 Imaging2026-03-05 18:23
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025771291_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-03-05 to 2026-06-03.
- Itemized billitemized_PA-707979.pdf6 pages
Itemised statement totalling $3640.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012068 | 2026-09-11 | Mesa Physical Therapy | $152.00 | Approved |
| CLM-2026-015990 | 2026-04-30 | Harbor Physical Therapy | $416.00 | Approved |
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.