CLM-2026-005593
Lakeside Imaging Center, Radiology. Service 2026-08-27 at outpatient hospital (POS 22). Received 2026-09-12.
Member
Resolved through the identity graph
- Member
- Bradley Crawford
- Member ID
- UHC-16738-82
- Date of birth
- 1960-03-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-427743
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4379
- Coverage period
- 2025-06-01 to 2026-03-05
- Deductible
- $1,172.55 of $2,500.0047%
- Out-of-pocket maximum
- $2,978.94 of $7,500.0040%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3836779710
- Network
- In network
- Rendering NPI
- 3836779710
- Location
- Nashville, TN · TIN 29-1460766
- Authorisation / referral
- PA2025700989 / 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 | $419.00 | $230.45 | — | — | DeniedCO27 |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $1,895.00 | $1,042.25 | — | — | DeniedCO27 |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,039.00 | $1,121.45 | — | — | DeniedCO27 |
| Totals | $4,353.00 | $2,394.15 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-720136
- 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-024965 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-27 is after coverage terminated on 2026-03-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025700989 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (3836779710). | |
| 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 Center2026-08-27 10:04
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-09-12 06:55
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-12 12:22
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025700989_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-08-27 to 2026-11-25.
- Itemized billitemized_PA-720136.pdf9 pages
Itemised statement totalling $4353.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-27 is after coverage terminated on 2026-03-05.
Other claims for this member
Same resolved identity
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
Service after coverage termination.