CLM-2026-031990
Canyon Diagnostic Imaging, Radiology. Service 2026-09-25 at outpatient hospital (POS 22). Received 2026-10-01.
Member
Resolved through the identity graph
- Member
- Olivia Davis
- Member ID
- UHC-46336-83
- Date of birth
- 1995-11-18
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-422107
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5439
- Coverage period
- 2025-11-01 to present
- Deductible
- $310.85 of $500.0062%
- Out-of-pocket maximum
- $502.24 of $1,500.0033%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8055565153
- Network
- In network
- Rendering NPI
- 8055565153
- Location
- Atlanta, GA · TIN 44-7708549
- 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,925.00 | $1,608.75 | — | — | DeniedCO197 |
| Totals | $2,925.00 | $1,608.75 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-783880
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003808 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-09-25: CHOICE-PLUS-PPO (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (8055565153). | |
| 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: Canyon Diagnostic Imaging2026-09-25 13:48
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-10-01 05:39
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-783880.pdf4 pages
Itemised statement totalling $2925.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 70553 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.