CLM-2026-001038
Sunrise Imaging Center, Radiology. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Benjamin Contreras
- Member ID
- UHC-74433-78
- Date of birth
- 1980-06-23
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-414941
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9082
- Coverage period
- 2024-10-01 to 2026-05-05
- Deductible
- $309.32 of $1,500.0021%
- Out-of-pocket maximum
- $1,871.77 of $4,500.0042%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 20 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,419.00 | $1,330.45 | — | — | DeniedCO197 |
| Totals | $2,419.00 | $1,330.45 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-876698
- 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-013639 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-08: NAVIGATE-HMO (HMO), effective 2024-10-01, terms 2026-05-05. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2026-01-08 16:36
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-16 02:35
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-16 10:49
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-876698.pdf9 pages
Itemised statement totalling $2419.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 70553 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032320 | 2026-10-07 | Sunrise Behavioral Health | $547.00 | Denied |
| CLM-2026-028361 | 2026-06-14 | Valley Medical Group | $503.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.