CLM-2026-003498
Lakeside Imaging Center, Radiology. Service 2026-05-22 at outpatient hospital (POS 22). Received 2026-06-13.
Member
Resolved through the identity graph
- Member
- Christian Marshall
- Member ID
- UHC-23971-08
- Date of birth
- 1949-12-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-401072
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7713
- Coverage period
- 2024-12-01 to 2026-03-23
- Deductible
- $1,233.11 of $3,500.0035%
- Out-of-pocket maximum
- $757.37 of $10,500.007%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4829743648
- Network
- In network
- Rendering NPI
- 4829743648
- Location
- Minneapolis, MN · TIN 87-3632325
- Authorisation / referral
- PA2026622280 / 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 | $524.00 | $288.20 | — | — | DeniedCO27 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $145.00 | $79.75 | — | — | DeniedCO27 |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $2,300.00 | $1,265.00 | — | — | DeniedCO27 |
| Totals | $2,969.00 | $1,632.95 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-822912
- 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-034700 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-22 is after coverage terminated on 2026-03-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026622280 on file for 74177. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (4829743648). | |
| 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 Center2026-05-22 11:46
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-06-13 05:02
Attachments
Documents received with the claim
- Prior auth letterPA2026622280_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-05-22 to 2026-08-20.
- Itemized billitemized_PA-822912.pdf4 pages
Itemised statement totalling $2969.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-22 is after coverage terminated on 2026-03-23.
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
Service after coverage termination.