Institutional claim · UB-04 · Paper
CLM-2026-004489
Summit Diagnostic Imaging, Radiology. Service 2026-09-25 at outpatient hospital (POS 22). Received 2026-10-18.
Approved
Billed
$759.00
2 lines
Allowed
$417.45
contract rate applied
Plan pays
$105.86
approved
Member owes
$311.59
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Thomas Walker
- Member ID
- UHC-98355-06
- Date of birth
- 1999-03-19
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-410558
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9646
- Coverage period
- 2024-10-01 to present
- Deductible
- $714.87 of $1,000.0071%
- Out-of-pocket maximum
- $724.33 of $3,000.0024%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8935049519
- Network
- In network
- Rendering NPI
- 8935049519
- Location
- Los Angeles, CA · TIN 90-8085018
- Authorisation / referral
- none / 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 | $293.00 | $161.15 | $161.15 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $466.00 | $256.30 | $150.44 | $105.86 | Paid |
| Totals | $759.00 | $417.45 | $311.59 | $105.86 | ||||||
Diagnoses (ICD-10-CM)
- 1. R51.9 Headache, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
Claim header
- Patient account
- PA-435328
- 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-014659 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-25: SELECT-EPO (EPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Diagnostic Imaging (8935049519). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Diagnostic Imaging2026-09-25 15:07
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-435328.pdf9 pages
Itemised statement totalling $759.00 across 2 lines.
Explanation of benefits
What the member will see
Amount billed
$759.00
Plan discount
$341.55
contracted rate
Plan paid
$105.86
You may owe
$311.59
copay, deductible and coinsurance
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-2026-024333 | 2026-09-15 | Riverside Digestive Health Center | $2,964.00 | Approved |
| CLM-2026-030689 | 2026-07-06 | Northgate Clinical Laboratories | $50.00 | Denied |
| CLM-2026-030688 | 2026-07-06 | Northgate Clinical Laboratories | $50.00 | Approved |
| CLM-2026-014507 | 2026-05-28 | Heritage Primary Care Associates | $504.00 | Approved |
| CLM-2026-025389 | 2026-06-09 | Mesa Primary Care Associates | $188.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.