CLM-2026-000586
Unity Imaging Center, Radiology. Service 2026-01-17 at outpatient hospital (POS 22). Received 2026-02-23.
Member
Resolved through the identity graph
- Member
- Samuel Mejia
- Member ID
- UHC-08695-80
- Date of birth
- 2003-07-13
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-401545
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8910
- Coverage period
- 2023-09-01 to present
- Deductible
- $74.14 of $500.0015%
- Out-of-pocket maximum
- $204.75 of $1,000.0020%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 8566952718
- Network
- Out of network
- Rendering NPI
- 8566952718
- Location
- Miami, FL · TIN 34-7730969
- 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 | $325.00 | $146.25 | $146.25 | $0.00 | Paid |
| Totals | $325.00 | $146.25 | $146.25 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-328954
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015347 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-17: NULL (PPO), effective 2023-09-01. | |
| 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Unity Imaging Center2026-01-17 14:34
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-328954.pdf7 pages
Itemised statement totalling $325.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.