CLM-2026-008010
Heritage Imaging Center, Radiology. Service 2026-07-12 at outpatient hospital (POS 22). Received 2026-08-03.
Member
Resolved through the identity graph
- Member
- Frank Padilla
- Member ID
- UHC-18739-54
- Date of birth
- 1964-02-14
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-405256
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3480
- Coverage period
- 2023-06-01 to present
- Deductible
- $1,729.38 of $3,500.0049%
- Out-of-pocket maximum
- $4,676.32 of $14,000.0033%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4466693437
- Network
- In network
- Rendering NPI
- 4466693437
- Location
- Atlanta, GA · TIN 36-7680074
- Authorisation / referral
- none / REF128919
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 | $374.00 | $205.70 | $205.70 | $0.00 | Paid |
| Totals | $374.00 | $205.70 | $205.70 | $0.00 | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-669404
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019806 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-12: CORE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 22 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 Heritage Imaging Center (4466693437). | |
| 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: Heritage Imaging Center2026-07-12 16:16
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-669404.pdf2 pages
Itemised statement totalling $374.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018021 | 2026-08-04 | Pinecrest Behavioral Health | $220.00 | Needs review |
| CLM-2026-018020 | 2026-08-04 | Sunrise Counseling Center | $220.00 | Approved |
| CLM-2026-024733 | 2026-04-24 | Riverside Orthopedic Specialists | $8,953.00 | Denied |
| CLM-2026-030057 | 2026-02-26 | Riverside Internal Medicine Associates | $222.00 | Denied |
| CLM-2026-011315 | 2026-02-09 | Heritage Medical Group | $411.00 | 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
Clean claim, priced at contract rate.