CLM-2026-007379
Lakeside Imaging Center, Radiology. Service 2026-06-14 at outpatient hospital (POS 22). Received 2026-07-17.
Member
Resolved through the identity graph
- Member
- Aisha Martinez
- Member ID
- UHC-74899-52
- Date of birth
- 1982-02-27
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400366
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2753
- Coverage period
- 2021-04-01 to present
- Deductible
- $200.18 of $1,500.0013%
- Out-of-pocket maximum
- $1,160.08 of $3,000.0039%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 2856185642
- Network
- In network
- Rendering NPI
- 2856185642
- Location
- Miami, FL · TIN 71-0753822
- Authorisation / referral
- PA2025249178 / 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 | $294.00 | $161.70 | — | — | Review |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 2 | $2,370.00 | $1,303.50 | — | — | Review |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $2,037.00 | $1,120.35 | — | — | Review |
| Totals | $4,701.00 | $2,585.55 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-634747
- 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-038758 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-14: NULL (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025249178 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (2856185642). | |
| Medical necessity | Review | CO50 | 74177, 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Center2026-06-14 17:50
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025249178_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-06-14 to 2026-09-12.
- Itemized billitemized_PA-634747.pdf3 pages
Itemised statement totalling $4701.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 74177, 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
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.