CLM-2026-005996
Summit Diagnostic Imaging, Radiology. Service 2026-05-04 at outpatient hospital (POS 22). Received 2026-05-10.
Member
Resolved through the identity graph
- Member
- Katherine Carter
- Member ID
- UHC-19218-47
- Date of birth
- 1963-12-21
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-412343
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group -
- Coverage period
- 2021-04-01 to present
- Deductible
- $3,136.71 of $3,500.0090%
- Out-of-pocket maximum
- $2,296.67 of $14,000.0016%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8935049519
- Network
- In network
- Rendering NPI
- 8935049519
- Location
- Los Angeles, CA · TIN 90-8085018
- 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 | $156.00 | $85.80 | $85.80 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $558.00 | $306.90 | $286.31 | $20.59 | Paid |
| Totals | $714.00 | $392.70 | $372.11 | $20.59 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-926251
- 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-011815 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-04: OPTIONS-PPO (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 6 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 Summit Diagnostic Imaging (8935049519). | |
| 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: Summit Diagnostic Imaging2026-05-04 12:45
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Itemized billitemized_PA-926251.pdf3 pages
Itemised statement totalling $714.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028502 | 2025-12-30 | Lakeside Imaging Center | $3,712.00 | 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.