CLM-2026-032722
Riverside Imaging Center, Radiology. Service 2026-05-16 at outpatient hospital (POS 22). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Sara Andrews
- Member ID
- UHC-45537-10
- Date of birth
- 1961-11-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411027
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group NULL
- Coverage period
- 2025-10-01 to present
- Deductible
- $48.45 of $500.0010%
- Out-of-pocket maximum
- $199.93 of $2,000.0010%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7427092680
- Network
- In network
- Rendering NPI
- 7427092680
- Location
- Mesa, AZ · TIN 33-8428995
- Authorisation / referral
- PA2025174518 / 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 | $1,403.00 | $771.65 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,817.00 | $1,549.35 | — | — | Review |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $186.00 | $102.30 | — | — | Review |
| Totals | $4,406.00 | $2,423.30 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-884748
- 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-034288 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-16: N/A (PPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025174518 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Riverside Imaging Center (7427092680). | |
| Medical necessity | Review | CO50 | 74177, 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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: Riverside Imaging Center2026-05-16 16:13
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025174518_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-05-16 to 2026-08-14.
- Itemized billitemized_PA-884748.pdf4 pages
Itemised statement totalling $4406.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 74177, 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024494 | 2026-08-25 | Heritage Community Hospital | $2,923.00 | Approved |
| CLM-2026-001302 | 2026-08-28 | Meadow Family Practice | $232.00 | Approved |
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
Clean claim, priced at contract rate.