CLM-2026-007915
Sunrise Diagnostic Imaging, Radiology. Service 2026-01-04 at outpatient hospital (POS 22). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Kimberly Stephens
- Member ID
- UHC-60875-27
- Date of birth
- 1939-11-27
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423753
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6549
- Coverage period
- 2024-11-01 to present
- Deductible
- $1,936.29 of $3,500.0055%
- Out-of-pocket maximum
- $3,833.64 of $14,000.0027%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8125654300
- Network
- In network
- Rendering NPI
- 8125654300
- Location
- Scottsdale, AZ · TIN 88-4094032
- Authorisation / referral
- PA2026699300 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,310.00 | $720.50 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $2,710.00 | $1,490.50 | — | — | Review |
| Totals | $4,020.00 | $2,211.00 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-154949
- 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-006521 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-04: SELECT-EPO (EPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026699300 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Sunrise Diagnostic Imaging (8125654300). | |
| 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: Sunrise Diagnostic Imaging2026-01-04 16:05
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026699300_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-01-04 to 2026-04-04.
- Itemized billitemized_PA-154949.pdf7 pages
Itemised statement totalling $4020.00 across 2 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.
- AI recommendationPended2026-10-23 19:19The claim has been flagged for medical necessity (CO50) as the billed services (CT abdomen and pelvis with contrast and MRI brain with and without contrast) are associated with a routine diagnosis (Z12.31). The clinical note provided does not explicitly support the medical necessity of these services. The examiner should verify if the clinical notes provide sufficient justification for the services provided.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:19 · 4a092514
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO50 Not medically necessary per payer policy
The claim has been flagged for medical necessity (CO50) as the billed services (CT abdomen and pelvis with contrast and MRI brain with and without contrast) are associated with a routine diagnosis (Z12.31). The clinical note provided does not explicitly support the medical necessity of these services. The examiner should verify if the clinical notes provide sufficient justification for the services provided.
- Verify if the clinical notes support the medical necessity of the CT abdomen and pelvis with contrast and MRI brain with and without contrast for the given diagnoses.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO50 Not medically necessary per payer policy
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.