CLM-2026-006041
Sunrise Imaging Center, Radiology. Service 2026-02-07 at outpatient hospital (POS 22). Received 2026-03-21.
Member
Resolved through the identity graph
- Member
- Hannah Nelson
- Member ID
- UHC-54516-18
- Date of birth
- 1987-03-10
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-428512
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5702
- Coverage period
- 2022-07-01 to present
- Deductible
- $1,323.51 of $3,500.0038%
- Out-of-pocket maximum
- $2,824.81 of $10,500.0027%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9630195771
- Network
- Out of network
- Rendering NPI
- 9630195771
- Location
- Dallas, TX · TIN 60-5457120
- Authorisation / referral
- PA2026436115 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,525.00 | $1,136.25 | — | — | Review |
| Totals | $2,525.00 | $1,136.25 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-112558
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002099 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-02-07: CHOICE-PLUS-PPO (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026436115 on file for 74177. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Review | CO50 | 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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: Sunrise Imaging Center2026-02-07 14:53
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026436115_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-02-07 to 2026-05-08.
- Itemized billitemized_PA-112558.pdf9 pages
Itemised statement totalling $2525.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033743 | 2026-06-03 | Pinecrest Internal Medicine Associates | $90.00 | Approved |
| CLM-2026-008580 | 2025-12-24 | Mesa Primary Care Associates | $311.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.