CLM-2026-002570
Sunrise Imaging Center, Radiology. Service 2025-11-19 at outpatient hospital (POS 22). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Emma Sanders
- Member ID
- UHC-54455-12
- Date of birth
- 1948-08-06
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-420588
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1150
- Coverage period
- 2022-09-01 to 2026-06-01
- Deductible
- $15.73 of $1,500.001%
- Out-of-pocket maximum
- $262.00 of $3,000.009%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $471.00 | $259.05 | — | — | DeniedCO29 |
| Totals | $471.00 | $259.05 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. R51.9 Headache, unspecified
- Patient account
- PA-618338
- 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-021491 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-19: CHOICE-PLUS-PPO (PPO), effective 2022-09-01, terms 2026-06-01. | |
| Timely filing | Fail | CO29 | Received 124 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (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 Center2025-11-19 15:50
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-23 00:04
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-618338.pdf9 pages
Itemised statement totalling $471.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 124 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001948 | 2026-05-09 | Heritage Primary Care Associates | $203.00 | Approved |
| CLM-2026-003953 | 2026-04-25 | Desert Heart Institute | $1,586.00 | Denied |
| CLM-2026-003952 | 2026-04-25 | Desert Heart Institute | $1,586.00 | Approved |
| CLM-2026-028126 | 2026-02-08 | Desert Medical Group | $14.00 | 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
Received after the timely-filing limit.