CLM-2026-004000
Lakeside Imaging Center, Radiology. Service 2026-04-21 at outpatient hospital (POS 22). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Kathryn Lawson
- Member ID
- UHC-96469-23
- Date of birth
- 1941-09-02
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-405512
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9399
- Coverage period
- 2023-12-01 to present
- Deductible
- $351.11 of $500.0070%
- Out-of-pocket maximum
- $929.04 of $2,000.0046%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 1 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
- PA2026277690 / 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 | $300.00 | $165.00 | $150.50 | $14.50 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,338.00 | $1,285.90 | $128.59 | $1,157.31 | Paid |
| Totals | $2,638.00 | $1,450.90 | $279.09 | $1,171.81 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-418737
- 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-031304 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-21: NULL (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026277690 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 Center2026-04-21 18:28
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Prior auth letterPA2026277690_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-04-21 to 2026-07-20.
- Itemized billitemized_PA-418737.pdf2 pages
Itemised statement totalling $2638.00 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-2026-022703 | 2026-09-16 | Lakeside Physical Therapy | $236.00 | Approved |
| CLM-2026-013963 | 2026-06-07 | Sunrise Community Hospital | $892.00 | Denied |
| CLM-2026-013962 | 2026-06-07 | Sunrise Community Hospital | $892.00 | Approved |
| CLM-2026-007141 | 2026-06-15 | Heritage Primary Care Associates | $490.00 | 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.