CLM-2026-004173
Lakeside Imaging Center, Radiology. Service 2026-03-02 at outpatient hospital (POS 22). Received 2026-04-03.
Member
Resolved through the identity graph
- Member
- George Lopez
- Member ID
- UHC-53502-65
- Date of birth
- 1951-11-13
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-420526
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group NULL
- Coverage period
- 2024-01-01 to present
- Deductible
- $368.55 of $500.0074%
- Out-of-pocket maximum
- $353.27 of $2,000.0018%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3836779710
- Network
- In network
- Rendering NPI
- 3836779710
- Location
- Nashville, TN · TIN 29-1460766
- Authorisation / referral
- PA2026015293 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,692.00 | $930.60 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 2 | $194.00 | $106.70 | — | — | Review |
| Totals | $1,886.00 | $1,037.30 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-678036
- 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-022564 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-02: MEDICARE-ADV-B (MA), effective 2024-01-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026015293 on file for 74177. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (3836779710). | |
| Medical necessity | Review | CO50 | 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Center2026-03-02 14:43
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Prior auth letterPA2026015293_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-03-02 to 2026-05-31.
- Itemized billitemized_PA-678036.pdf9 pages
Itemised statement totalling $1886.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007462 | 2026-07-17 | Summit Diagnostic Imaging | $387.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.