CLM-2026-004896
Unity Diagnostic Imaging, Radiology. Service 2026-05-17 at outpatient hospital (POS 22). Received 2026-06-14.
Member
Resolved through the identity graph
- Member
- Bradley Lane
- Member ID
- UHC-88564-99
- Date of birth
- 1938-01-06
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421032
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9510
- Coverage period
- 2024-12-01 to present
- Deductible
- $647.43 of $1,000.0065%
- Out-of-pocket maximum
- $1,223.63 of $3,000.0041%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1910682917
- Network
- In network
- Rendering NPI
- 1910682917
- Location
- Mesa, AZ · TIN 81-0269629
- 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 | $292.00 | $160.60 | $160.60 | $0.00 | Paid |
| Totals | $292.00 | $160.60 | $160.60 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-300562
- 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-033864 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-17: MEDICARE-ADV-A (MA), effective 2024-12-01. | |
| 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 Unity Diagnostic Imaging (1910682917). | |
| 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: Unity Diagnostic Imaging2026-05-17 14:27
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-300562.pdf6 pages
Itemised statement totalling $292.00 across 1 line.
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-2026-006217 | 2026-06-05 | Mesa Orthopedic Specialists | $249.00 | Approved |
| CLM-2026-011606 | 2026-06-03 | Unity Clinical Laboratories | $178.00 | 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.