CLM-2026-004451
Sunrise Imaging Center, Radiology. Service 2025-08-26 at outpatient hospital (POS 22). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Camila Walker
- Member ID
- UHC-54715-07
- Date of birth
- 1964-02-22
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-428936
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3019
- Coverage period
- 2021-08-01 to present
- Deductible
- $2,044.86 of $2,500.0082%
- Out-of-pocket maximum
- $3,708.52 of $7,500.0049%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4303980450
- Network
- In network
- Rendering NPI
- 4303980450
- Location
- Miami, FL · TIN 94-2880728
- Authorisation / referral
- PA2026553342 / 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 | $348.00 | $191.40 | — | — | DeniedCO29 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $208.00 | $114.40 | — | — | DeniedCO29 |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $3,061.00 | $1,683.55 | — | — | DeniedCO29 |
| Totals | $3,617.00 | $1,989.35 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-757029
- 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-023018 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-08-26: SELECT-EPO (EPO), effective 2021-08-01. | |
| Timely filing | Fail | CO29 | Received 216 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026553342 on file for 70553. | |
| Provider network | Pass | In-network provider Sunrise Imaging Center (4303980450). | |
| 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 Center2025-08-26 16:44
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-03-30 00:10
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026553342_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2025-08-26 to 2025-11-24.
- Itemized billitemized_PA-757029.pdf7 pages
Itemised statement totalling $3617.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 216 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017014 | 2026-07-19 | Evergreen Counseling Center | $230.00 | Approved |
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
Received after the timely-filing limit.