CLM-2026-002905
Heritage Imaging Center, Radiology. Service 2026-09-14 at outpatient hospital (POS 22). Received 2026-09-22.
Member
Resolved through the identity graph
- Member
- Janice Jordan
- Member ID
- UHC-98712-15
- Date of birth
- 1966-03-24
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-424587
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-3331
- Coverage period
- 2022-01-01 to present
- Deductible
- $1,962.33 of $3,500.0056%
- Out-of-pocket maximum
- $1,405.10 of $7,000.0020%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4466693437
- Network
- In network
- Rendering NPI
- 4466693437
- Location
- Atlanta, GA · TIN 36-7680074
- 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 | $613.00 | $337.15 | $337.15 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1,2 | $301.00 | $165.55 | $165.55 | $0.00 | Paid |
| Totals | $914.00 | $502.70 | $502.70 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-929569
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008058 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-14: UNKNOWN (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 8 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 Heritage Imaging Center (4466693437). | |
| 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: Heritage Imaging Center2026-09-14 17:24
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-929569.pdf9 pages
Itemised statement totalling $914.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025567 | 2026-08-24 | Sunrise Dermatology Clinic | $369.00 | Approved |
| CLM-2026-023482 | 2026-01-21 | Northgate Cardiovascular Associates | $535.00 | 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.