CLM-2026-006435
Summit Diagnostic Imaging, Radiology. Service 2026-03-30 at outpatient hospital (POS 22). Received 2026-04-18.
Member
Resolved through the identity graph
- Member
- Amy Mendoza
- Member ID
- UHC-78961-66
- Date of birth
- 1961-09-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-424816
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9806
- Coverage period
- 2021-10-01 to present
- Deductible
- $285.28 of $500.0057%
- Out-of-pocket maximum
- $216.64 of $1,500.0014%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- 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 / REF865530
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 | $279.00 | $153.45 | $153.45 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | 25 | 1 | 1 | $437.00 | $240.35 | $79.18 | $161.17 | Paid |
| Totals | $716.00 | $393.80 | $232.63 | $161.17 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-185449
- 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-026526 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-30: CORE-HMO (HMO), effective 2021-10-01. | |
| Timely filing | Pass | Received 19 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 Imaging2026-03-30 10:43
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-185449.pdf4 pages
Itemised statement totalling $716.00 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
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.