CLM-2026-000364
Sunrise Imaging Center, Radiology. Service 2026-08-01 at outpatient hospital (POS 22). Received 2026-09-07.
Member
Resolved through the identity graph
- Member
- Mariana Anderson
- Member ID
- UHC-20476-18
- Date of birth
- 2000-10-14
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-408551
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6663
- Coverage period
- 2021-07-01 to present
- Deductible
- $2,213.52 of $3,500.0063%
- Out-of-pocket maximum
- $4,540.98 of $10,500.0043%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9418627425
- Network
- In network
- Rendering NPI
- 9418627425
- Location
- Mesa, AZ · TIN 78-4773350
- Authorisation / referral
- none / REF813886
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 | $304.00 | $167.20 | $167.20 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $209.00 | $114.95 | $114.95 | $0.00 | Paid |
| Totals | $513.00 | $282.15 | $282.15 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-258028
- 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-007549 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-01: CORE-HMO (HMO), effective 2021-07-01. | |
| Timely filing | Pass | Received 37 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 Sunrise Imaging Center (9418627425). | |
| 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: Sunrise Imaging Center2026-08-01 13:32
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-258028.pdf9 pages
Itemised statement totalling $513.00 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-2026-026145 | 2026-08-18 | Valley Skin Care Associates | $247.00 | Denied |
| CLM-2026-024747 | 2026-09-26 | Riverside Medical Group | $146.00 | Approved |
| CLM-2026-019821 | 2026-02-20 | Evergreen Medical Group | $528.00 | 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.