CLM-2026-002839
Sunrise Imaging Center, Radiology. Service 2026-05-14 at outpatient hospital (POS 22). Received 2026-05-16.
Member
Resolved through the identity graph
- Member
- George Maldonado
- Member ID
- UHC-54438-55
- Date of birth
- 2003-06-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-403900
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4486
- Coverage period
- 2024-11-01 to present
- Deductible
- $123.65 of $3,500.004%
- Out-of-pocket maximum
- $324.97 of $14,000.002%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9630195771
- Network
- Out of network
- Rendering NPI
- 9630195771
- Location
- Dallas, TX · TIN 60-5457120
- Authorisation / referral
- PA2025909993 / 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $350.00 | $157.50 | — | — | DeniedCO204 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 1 | $1,824.00 | $820.80 | — | — | DeniedCO204 |
| Totals | $2,174.00 | $978.30 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-852516
- 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-019022 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-14: SELECT-EPO (EPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 2 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025909993 on file for 74177. | |
| Provider network | Fail | CO204 | Billing provider 9630195771 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Center2026-05-14 09:29
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-05-16 06:18
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2025909993_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-05-14 to 2026-08-12.
- Itemized billitemized_PA-852516.pdf8 pages
Itemised statement totalling $2174.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 9630195771 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.