CLM-2026-001546
Unity Imaging Center, Radiology. Service 2026-08-04 at outpatient hospital (POS 22). Received 2026-08-09.
Member
Resolved through the identity graph
- Member
- Jack Clark
- Member ID
- UHC-74308-55
- Date of birth
- 1957-06-05
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-411499
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0478
- Coverage period
- 2022-02-01 to 2026-05-16
- Deductible
- $31.15 of $500.006%
- Out-of-pocket maximum
- $474.13 of $1,000.0047%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 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
- PA2025916804 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $174.00 | $78.30 | — | — | DeniedCO27 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $1,654.00 | $744.30 | — | — | DeniedCO27 |
| Totals | $1,828.00 | $822.60 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-195437
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000732 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-04 is after coverage terminated on 2026-05-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025916804 on file for 74177. | |
| 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 Center2026-08-04 16:55
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-08-09 00:57
Attachments
Documents received with the claim
- Prior auth letterPA2025916804_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-08-04 to 2026-11-02.
- Itemized billitemized_PA-195437.pdf7 pages
Itemised statement totalling $1828.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-04 is after coverage terminated on 2026-05-16. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026007 | 2026-04-28 | Canyon Medical Group | $336.00 | Approved |
| CLM-2026-034023 | 2026-04-28 | Pinecrest Heart Institute | $8,773.00 | Approved |
| CLM-2026-022811 | 2025-11-29 | Harbor Primary Care Associates | $582.00 | Approved |
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
Service after coverage termination.