CLM-2026-034644
Desert Diagnostic Imaging, Radiology. Service 2026-08-17 at outpatient hospital (POS 22). Received 2026-09-11.
Member
Resolved through the identity graph
- Member
- Christina Olson
- Member ID
- UHC-51600-71
- Date of birth
- 1966-06-01
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-427353
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0545
- Coverage period
- 2021-04-01 to present
- Deductible
- $809.10 of $1,000.0081%
- Out-of-pocket maximum
- $1,877.93 of $4,000.0047%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 11 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $373.00 | $205.15 | $192.33 | $12.82 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $383.00 | $210.65 | $21.07 | $189.58 | Paid |
| Totals | $756.00 | $415.80 | $213.40 | $202.40 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-252499
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000328 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-17: OPTIONS-PPO (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Imaging2026-08-17 12:09
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-252499.pdf7 pages
Itemised statement totalling $756.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007297 | 2025-11-30 | Lakeside Internal Medicine Associates | $314.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.