CLM-2026-008161
Riverside Diagnostic Imaging, Radiology. Service 2025-12-09 at outpatient hospital (POS 22). Received 2026-01-16.
Member
Resolved through the identity graph
- Member
- Rachel Baker
- Member ID
- UHC-32037-03
- Date of birth
- 2006-10-24
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-429675
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1941
- Coverage period
- 2021-04-01 to present
- Deductible
- $95.45 of $2,500.004%
- Out-of-pocket maximum
- $972.06 of $5,000.0019%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6802768252
- Network
- In network
- Rendering NPI
- 6802768252
- Location
- Scottsdale, AZ · TIN 85-0998777
- Authorisation / referral
- none / REF720618
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 | $276.00 | $151.80 | $151.80 | $0.00 | Paid |
| Totals | $276.00 | $151.80 | $151.80 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-711175
- 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-002200 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-09: CORE-HMO (HMO), effective 2021-04-01. | |
| Timely filing | Pass | Received 38 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 Riverside Diagnostic Imaging (6802768252). | |
| 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: Riverside Diagnostic Imaging2025-12-09 10:14
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-711175.pdf8 pages
Itemised statement totalling $276.00 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-2026-018250 | 2026-03-26 | Sunrise Medical Group | $583.00 | 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.