CLM-2026-004535
Lakeside Imaging Center, Radiology. Service 2025-12-06 at outpatient hospital (POS 22). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Shirley Obrien
- Member ID
- UHC-62601-51
- Date of birth
- 1969-06-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-423072
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4111
- Coverage period
- 2024-12-01 to present
- Deductible
- $2,515.55 of $3,500.0072%
- Out-of-pocket maximum
- $5,121.81 of $14,000.0037%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 2856185642
- Network
- In network
- Rendering NPI
- 2856185642
- Location
- Miami, FL · TIN 71-0753822
- Authorisation / referral
- PA2025900945 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $219.00 | $120.45 | $120.45 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,106.00 | $1,158.30 | $893.43 | $264.87 | Paid |
| Totals | $2,325.00 | $1,278.75 | $1,013.88 | $264.87 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-730125
- 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-003413 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-06: NULL (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025900945 on file for 74177. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (2856185642). | |
| 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: Lakeside Imaging Center2025-12-06 11:50
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025900945_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2025-12-06 to 2026-03-06.
- Itemized billitemized_PA-730125.pdf5 pages
Itemised statement totalling $2325.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021398 | 2026-08-06 | Canyon Counseling Center | $397.00 | Approved |
| CLM-2026-001765 | 2026-02-21 | Valley Imaging Center | $2,328.00 | Approved |
| CLM-2026-022256 | 2026-01-24 | Northgate Medical Group | $189.00 | 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.