CLM-2026-000488
Sunrise Imaging Center, Radiology. Service 2026-03-29 at outpatient hospital (POS 22). Received 2026-04-02.
Member
Resolved through the identity graph
- Member
- Juan Banks
- Member ID
- UHC-97584-08
- Date of birth
- 1967-11-12
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-422636
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6782
- Coverage period
- 2024-06-01 to present
- Deductible
- $257.63 of $500.0052%
- Out-of-pocket maximum
- $40.56 of $1,000.004%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4303980450
- Network
- In network
- Rendering NPI
- 4303980450
- Location
- Miami, FL · TIN 94-2880728
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $606.00 | $333.30 | $251.46 | $81.84 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | 25 | 1 | 1 | $387.00 | $212.85 | $21.29 | $191.56 | Paid |
| Totals | $993.00 | $546.15 | $272.75 | $273.40 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-393356
- 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-018241 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-29: CHOICE-PLUS-PPO (PPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 4 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 (4303980450). | |
| 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 Center2026-03-29 14:09
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-393356.pdf3 pages
Itemised statement totalling $993.00 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-2026-006008 | 2026-06-06 | Mesa Family Practice | $39.00 | Approved |
| CLM-2026-019416 | 2026-02-13 | Pinecrest Physical Therapy | $588.00 | Denied |
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.