CLM-2026-006479
Lakeside Imaging Center, Radiology. Service 2026-07-31 at outpatient hospital (POS 22). Received 2026-08-08.
Member
Resolved through the identity graph
- Member
- Brandon Rice
- Member ID
- UHC-75050-61
- Date of birth
- 1986-03-14
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-402652
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-5894
- Coverage period
- 2023-03-01 to present
- Deductible
- $601.59 of $3,500.0017%
- Out-of-pocket maximum
- $6,789.13 of $14,000.0048%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 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
- PA2025325887 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,448.00 | $1,346.40 | — | — | DeniedCO18 |
| Totals | $2,448.00 | $1,346.40 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-991127
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018672 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-31: N/A (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-006478: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | Authorisation PA2025325887 on file for 70553. | |
| 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 Center2026-07-31 12:47
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-08 03:09
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Prior auth letterPA2025325887_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-31 to 2026-10-29.
- Itemized billitemized_PA-991127.pdf7 pages
Itemised statement totalling $2448.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-006478: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000636 | 2026-08-12 | Sunrise Community Hospital | $3,769.00 | Approved |
| CLM-2026-006478 | 2026-07-31 | Lakeside Imaging Center | $2,448.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.