CLM-2026-006460
Sunrise Imaging Center, Radiology. Service 2026-07-24 at outpatient hospital (POS 22). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Jack Taylor
- Member ID
- none on golden record
- Date of birth
- 1971-03-07
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-427930
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-8902
- Coverage period
- 2021-08-01 to present
- Deductible
- $919.90 of $3,500.0026%
- Out-of-pocket maximum
- $2,853.51 of $7,000.0041%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9418627425
- Network
- In network
- Rendering NPI
- 9418627425
- Location
- Mesa, AZ · TIN 78-4773350
- Authorisation / referral
- PA2026399786 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $564.00 | $310.20 | — | — | PendedIDQ |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,793.00 | $1,536.15 | — | — | PendedIDQ |
| Totals | $3,357.00 | $1,846.35 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-801519
- 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 | Fail | IDQ | Member record is in open steward case CASE-002900; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-07-24: SELECT-EPO (EPO), effective 2021-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026399786 on file for 70553. | |
| Provider network | Pass | In-network provider Sunrise Imaging Center (9418627425). | |
| 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: Sunrise Imaging Center2026-07-24 15:39
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026399786_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-07-24 to 2026-10-22.
- Itemized billitemized_PA-801519.pdf7 pages
Itemised statement totalling $3357.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002900; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-24: SELECT-EPO (EPO), effective 2021-08-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
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.