CLM-2026-031808
Summit Imaging Center, Radiology. Service 2025-12-19 at outpatient hospital (POS 22). Received 2026-01-15.
Member
Resolved through the identity graph
- Member
- Scott Reynolds
- Member ID
- UHC-58037-43
- Date of birth
- 1944-05-06
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-401368
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6614
- Coverage period
- 2025-09-01 to present
- Deductible
- $2,234.25 of $2,500.0089%
- Out-of-pocket maximum
- $4,398.60 of $10,000.0044%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4562878908
- Network
- In network
- Rendering NPI
- 4562878908
- Location
- Minneapolis, MN · TIN 57-8653616
- 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 | 77067 rev 0403 | Screening mammography, bilateral | 59 | 1 | 1 | $225.00 | $123.75 | — | — | Review |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | 59 | 1 | 2 | $615.00 | $338.25 | — | — | Review |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $194.00 | $106.70 | — | — | Review |
| Totals | $1,034.00 | $568.70 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-805080
- 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-004625 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-19: MEDICARE-ADV-A (MA), effective 2025-09-01. | |
| Timely filing | Pass | Received 27 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 | Pass | In-network provider Summit Imaging Center (4562878908). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Summit Imaging Center2025-12-19 16:41
Patient seen for unspecified abdominal pain. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-15 06:32
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-15 09:19
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-805080.pdf5 pages
Itemised statement totalling $1034.00 across 3 lines.
- Medical recordrecords_PA-805080.pdf16 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-23 19:13The claim includes procedures that are normally bundled, and the clinical note [N1] confirms that both procedures were performed at the same site during the same session. The use of modifier 59 is not supported by the documentation, as required by the NCCI edit [R-ncci].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:13 · cd894080
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO97 Benefit included in another service already adjudicated
The claim includes procedures that are normally bundled, and the clinical note [N1] confirms that both procedures were performed at the same site during the same session. The use of modifier 59 is not supported by the documentation, as required by the NCCI edit [R-ncci].
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.