CLM-2026-002582
Lakeside Imaging Center, Radiology. Service 2026-01-22 at outpatient hospital (POS 22). Received 2026-02-10.
Member
Resolved through the identity graph
- Member
- Peter Walker
- Member ID
- UHC-17729-51
- Date of birth
- 1986-04-18
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-402082
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8113
- Coverage period
- 2022-12-01 to present
- Deductible
- $476.67 of $1,000.0048%
- Out-of-pocket maximum
- $864.21 of $3,000.0029%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 2856185642
- Network
- In network
- Rendering NPI
- 2856185642
- Location
- Miami, FL · TIN 71-0753822
- 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 | $2,975.00 | $1,636.25 | — | — | DeniedCO197 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 1,2 | $1,826.00 | $1,004.30 | — | — | DeniedCO197 |
| Totals | $4,801.00 | $2,640.55 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-298747
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010051 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-22: SELECT-EPO (EPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553, 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Lakeside Imaging Center (2856185642). | |
| 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: Lakeside Imaging Center2026-01-22 13:06
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-02-10 02:08
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-298747.pdf3 pages
Itemised statement totalling $4801.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 70553, 74177 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023768 | 2026-07-29 | Pinecrest Bone and Joint Center | $231.00 | Approved |
| CLM-2026-017433 | 2026-04-21 | Lakeside Behavioral Health | $255.00 | Denied |
| CLM-2026-029086 | 2026-01-28 | Cornerstone Clinical Laboratories | $164.00 | 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
Precertification required and absent.