CLM-2026-004092
Sunrise Imaging Center, Radiology. Service 2026-08-09 at outpatient hospital (POS 22). Received 2026-09-04.
Member
Resolved through the identity graph
- Member
- Carol Shaw
- Member ID
- UHC-74988-59
- Date of birth
- 2002-10-06
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-429525
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4146
- Coverage period
- 2025-04-01 to present
- Deductible
- $605.99 of $2,500.0024%
- Out-of-pocket maximum
- $2,180.27 of $10,000.0022%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9418627425
- Network
- In network
- Rendering NPI
- 9418627425
- Location
- Mesa, AZ · TIN 78-4773350
- Authorisation / referral
- PA2025192029 / REF445227
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $234.00 | $128.70 | $128.70 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | 25 | 1 | 1 | $529.00 | $290.95 | $290.95 | $0.00 | Paid |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,332.00 | $1,282.60 | $1,282.60 | $0.00 | Paid |
| Totals | $3,095.00 | $1,702.25 | $1,702.25 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-307403
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010567 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-09: NAVIGATE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025192029 on file for 74177. | |
| Provider network | Pass | In-network provider Sunrise Imaging Center (9418627425). | |
| 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 Center2026-08-09 11:10
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025192029_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-08-09 to 2026-11-07.
- Itemized billitemized_PA-307403.pdf9 pages
Itemised statement totalling $3095.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011777 | 2026-07-05 | Lakeside Skin Care Associates | $661.00 | 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.