CLM-2026-004813
Riverside Imaging Center, Radiology. Service 2026-07-17 at outpatient hospital (POS 22). Received 2026-08-14.
Member
Resolved through the identity graph
- Member
- Ralph Montgomery
- Member ID
- UHC-77781-56
- Date of birth
- 1968-03-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-418504
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9074
- Coverage period
- 2025-03-01 to present
- Deductible
- $1,058.10 of $1,500.0071%
- Out-of-pocket maximum
- $54.45 of $6,000.001%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7550181540
- Network
- In network
- Rendering NPI
- 7550181540
- Location
- Charlotte, NC · TIN 65-3901057
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $210.00 | $115.50 | $115.50 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1,2 | $386.00 | $212.30 | $212.30 | $0.00 | Paid |
| Totals | $596.00 | $327.80 | $327.80 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. M25.561 Pain in right knee
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-312477
- 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-006999 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-17: CORE-HMO (HMO), effective 2025-03-01. | |
| Timely filing | Pass | Received 28 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 Riverside Imaging Center (7550181540). | |
| 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: Riverside Imaging Center2026-07-17 17:35
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-312477.pdf4 pages
Itemised statement totalling $596.00 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-2026-017231 | 2026-05-28 | Summit Community Hospital | $250.00 | 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.