CLM-2026-006169
Lakeside Imaging Center, Radiology. Service 2026-01-12 at outpatient hospital (POS 22). Received 2026-02-26.
Member
Resolved through the identity graph
- Member
- Nancy George
- Member ID
- UHC-91005-74
- Date of birth
- 1946-06-28
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-401290
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3846
- Coverage period
- 2024-07-01 to present
- Deductible
- $169.98 of $1,500.0011%
- Out-of-pocket maximum
- $151.01 of $3,000.005%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4829743648
- Network
- In network
- Rendering NPI
- 4829743648
- Location
- Minneapolis, MN · TIN 87-3632325
- 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 | $324.00 | $178.20 | $178.20 | $0.00 | Paid |
| Totals | $324.00 | $178.20 | $178.20 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-241814
- 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-012862 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-12: MEDICARE-ADV-B (MA), effective 2024-07-01. | |
| Timely filing | Pass | Received 45 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 Lakeside Imaging Center (4829743648). | |
| 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 Center2026-01-12 12:59
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-241814.pdf7 pages
Itemised statement totalling $324.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022532 | 2026-06-29 | Meadow Skin Care Associates | $216.00 | Approved |
| CLM-2026-014371 | 2026-02-26 | Riverside Primary Care Associates | $161.00 | Approved |
| CLM-2026-010936 | 2026-01-11 | Riverside Bone and Joint Center | $1,593.00 | 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.