CLM-2026-004261
Sunrise Diagnostic Imaging, Radiology. Service 2026-09-02 at outpatient hospital (POS 22). Received 2026-09-26.
Member
Resolved through the identity graph
- Member
- Gregory Perez
- Member ID
- UHC-88894-40
- Date of birth
- 1948-09-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-418179
- Relationship
- Child, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9194
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,260.22 of $2,500.0050%
- Out-of-pocket maximum
- $4,308.37 of $10,000.0043%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8125654300
- Network
- In network
- Rendering NPI
- 8125654300
- Location
- Scottsdale, AZ · TIN 88-4094032
- Authorisation / referral
- PA2025226272 / 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 | $464.00 | $255.20 | $255.20 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,408.00 | $1,324.40 | $1,086.53 | $237.87 | Paid |
| Totals | $2,872.00 | $1,579.60 | $1,341.73 | $237.87 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-474210
- 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-005912 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-02: OPTIONS-PPO (PPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025226272 on file for 70553. | |
| Provider network | Pass | In-network provider Sunrise Diagnostic Imaging (8125654300). | |
| 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 Diagnostic Imaging2026-09-02 10:03
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025226272_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-09-02 to 2026-12-01.
- Itemized billitemized_PA-474210.pdf3 pages
Itemised statement totalling $2872.00 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-2026-006600 | 2026-01-17 | Pinecrest Medical Group | $608.00 | Needs review |
| CLM-2026-006599 | 2026-01-17 | Unity Primary Care Associates | $608.00 | Approved |
| CLM-2026-030945 | 2025-12-12 | Heritage Digestive Health Center | $228.00 | 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.