CLM-2026-000600
Summit Imaging Center, Radiology. Service 2026-04-07 at outpatient hospital (POS 22). Received 2026-05-02.
Member
Resolved through the identity graph
- Member
- Heather Ramirez
- Member ID
- UHC-38315-81
- Date of birth
- 1984-02-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-429786
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4167
- Coverage period
- 2024-01-01 to present
- Deductible
- $1,830.72 of $2,500.0073%
- Out-of-pocket maximum
- $2,000.95 of $7,500.0027%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4562878908
- Network
- In network
- Rendering NPI
- 4562878908
- Location
- Minneapolis, MN · TIN 57-8653616
- Authorisation / referral
- none / REF579115
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 | $253.00 | $139.15 | $139.15 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $148.00 | $81.40 | $81.40 | $0.00 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $507.00 | $278.85 | $278.85 | $0.00 | Paid |
| Totals | $908.00 | $499.40 | $499.40 | $0.00 | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-962269
- 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-004659 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-07: NAVIGATE-HMO (HMO), effective 2024-01-01. | |
| 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 Summit Imaging Center (4562878908). | |
| 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: Summit Imaging Center2026-04-07 15:25
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-962269.pdf9 pages
Itemised statement totalling $908.00 across 3 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-2026-016958 | 2026-02-10 | Evergreen Family Practice | $523.00 | Approved |
| CLM-2026-002373 | 2025-12-25 | Mesa Physical Therapy | $128.00 | 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.