CLM-2026-005979
Heritage Imaging Center, Radiology. Service 2026-07-13 at outpatient hospital (POS 22). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Carlos Payne
- Member ID
- UHC-37293-70
- Date of birth
- 1954-12-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431838
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7688
- Coverage period
- 2025-08-01 to present
- Deductible
- $479.12 of $2,500.0019%
- Out-of-pocket maximum
- $2,566.99 of $7,500.0034%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4466693437
- Network
- In network
- Rendering NPI
- 4466693437
- Location
- Atlanta, GA · TIN 36-7680074
- Authorisation / referral
- none / REF876077
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 | $233.00 | $128.15 | $128.15 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | 25 | 1 | 2 | $490.00 | $269.50 | $269.50 | $0.00 | Paid |
| Totals | $723.00 | $397.65 | $397.65 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-568335
- 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-017952 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-13: CORE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Pass | Received 8 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 Heritage Imaging Center (4466693437). | |
| 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: Heritage Imaging Center2026-07-13 13:52
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-568335.pdf6 pages
Itemised statement totalling $723.00 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-2026-005980 | 2026-07-13 | Heritage Imaging Center | $723.00 | Denied |
| CLM-2026-021902 | 2026-02-20 | Meadow Cardiovascular Associates | $676.00 | 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.