CLM-2026-033445
Mesa Imaging Center, Radiology. Service 2025-12-08 at outpatient hospital (POS 22). Received 2026-01-19.
Member
Resolved through the identity graph
- Member
- Justin Jenkins
- Member ID
- UHC-82017-93
- Date of birth
- 1968-07-03
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422120
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group NULL
- Coverage period
- 2022-06-01 to present
- Deductible
- $947.20 of $2,500.0038%
- Out-of-pocket maximum
- $1,553.42 of $7,500.0021%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 6656135814
- Network
- Out of network
- Rendering NPI
- 6656135814
- Location
- Minneapolis, MN · TIN 75-3868074
- Authorisation / referral
- PA2025203057 / 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 | $178.00 | $80.10 | — | — | DeniedCO204 |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $2,944.00 | $1,324.80 | — | — | DeniedCO204 |
| Totals | $3,122.00 | $1,404.90 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-717698
- 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-005682 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-08: SELECT-EPO (EPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025203057 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 6656135814 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Mesa Imaging Center2025-12-08 13:00
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-19 03:35
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-19 13:29
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025203057_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2025-12-08 to 2026-03-08.
- Itemized billitemized_PA-717698.pdf6 pages
Itemised statement totalling $3122.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 6656135814 is out of network and the EPO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.