CLM-2026-034449
Canyon Diagnostic Imaging, Radiology. Service 2026-08-06 at outpatient hospital (POS 22). Received 2026-08-19.
Member
Resolved through the identity graph
- Member
- Elijah Owens
- Member ID
- UHC-18979-40
- Date of birth
- 1953-05-21
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431094
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group NULL
- Coverage period
- 2023-08-01 to present
- Deductible
- $676.92 of $2,500.0027%
- Out-of-pocket maximum
- $1,791.26 of $10,000.0018%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1352145704
- Network
- In network
- Rendering NPI
- 1352145704
- Location
- Atlanta, GA · TIN 24-1782323
- Authorisation / referral
- PA2025225735 / REF462404
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 | $1,794.00 | $986.70 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 1,2 | $2,426.00 | $1,334.30 | — | — | Review |
| 3 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $342.00 | $188.10 | — | — | Review |
| Totals | $4,562.00 | $2,509.10 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- 3. R51.9 Headache, unspecified
- Patient account
- PA-726394
- 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-023224 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-06: CORE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025225735 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Canyon Diagnostic Imaging (1352145704). | |
| 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: Canyon Diagnostic Imaging2026-08-06 18:50
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Prior auth letterPA2025225735_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-06 to 2026-11-04.
- Itemized billitemized_PA-726394.pdf2 pages
Itemised statement totalling $4562.00 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
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.