CLM-2026-001204
Sunrise Imaging Center, Radiology. Service 2026-09-28 at outpatient hospital (POS 22). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Debra Hoffman
- Member ID
- UHC-18077-63
- Date of birth
- 1983-03-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-422962
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5315
- Coverage period
- 2023-07-01 to present
- Deductible
- $78.34 of $3,500.002%
- Out-of-pocket maximum
- $1,167.52 of $7,000.0017%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 16 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 / REF270321
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 | $248.00 | $136.40 | $136.40 | $0.00 | Paid |
| Totals | $248.00 | $136.40 | $136.40 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-268805
- 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-017186 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-28: CORE-HMO (HMO), effective 2023-07-01. | |
| Timely filing | Pass | Received 13 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 Center2026-09-28 14:22
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-268805.pdf6 pages
Itemised statement totalling $248.00 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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024968 | 2026-02-05 | Valley Regional Medical Center | $1,798.00 | 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.