CLM-2026-007234
Summit Imaging Center, Radiology. Service 2026-09-09 at outpatient hospital (POS 22). Received 2026-09-13.
Member
Resolved through the identity graph
- Member
- Joseph Turner
- Member ID
- UHC-12535-13
- Date of birth
- 1957-06-14
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-427235
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0928
- Coverage period
- 2021-10-01 to present
- Deductible
- $1,262.70 of $1,500.0084%
- Out-of-pocket maximum
- $1,040.91 of $3,000.0035%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4562878908
- Network
- In network
- Rendering NPI
- 4562878908
- Location
- Minneapolis, MN · TIN 57-8653616
- Authorisation / referral
- none / REF583988
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 | $414.00 | $227.70 | $227.70 | $0.00 | Paid |
| Totals | $414.00 | $227.70 | $227.70 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-325785
- 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-025263 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-09: CORE-HMO (HMO), effective 2021-10-01. | |
| Timely filing | Pass | Received 4 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 Imaging Center (4562878908). | |
| 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 Imaging Center2026-09-09 18:53
Follow-up for headache, unspecified. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-09-13 06:40
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-325785.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-325785.pdf2 pages
Itemised statement totalling $414.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023077 | 2026-07-25 | Heritage Primary Care Associates | $448.00 | Approved |
| CLM-2026-001086 | 2026-03-19 | Summit Family Practice | $300.00 | 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
Authorisation must be confirmed with UM before payment.