CLM-2026-034522
Desert Diagnostic Imaging, Radiology. Service 2026-05-24 at outpatient hospital (POS 22). Received 2026-06-23.
Member
Resolved through the identity graph
- Member
- Samantha Henderson
- Member ID
- UHC-28244-02
- Date of birth
- 1945-01-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416668
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6522
- Coverage period
- 2022-02-01 to present
- Deductible
- $570.73 of $1,000.0057%
- Out-of-pocket maximum
- $183.53 of $3,000.006%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 3515366425
- Network
- In network
- Rendering NPI
- 3515366425
- Location
- Phoenix, AZ · TIN 68-2801174
- 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 | $1,825.00 | $1,003.75 | — | — | DeniedCO197 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $200.00 | $110.00 | — | — | DeniedCO197 |
| Totals | $2,025.00 | $1,113.75 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-349153
- 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-022562 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-24: MEDICARE-ADV-B (MA), effective 2022-02-01. | |
| Timely filing | Pass | Received 30 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 Desert Diagnostic Imaging (3515366425). | |
| 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: Desert Diagnostic Imaging2026-05-24 18:40
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-06-23 06:38
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-23 08:27
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-349153.pdf5 pages
Itemised statement totalling $2025.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 70553 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031726 | 2026-06-21 | Northgate Counseling Center | $276.00 | Denied |
| CLM-2026-031725 | 2026-06-21 | Northgate Counseling Center | $276.00 | Approved |
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.