CLM-2026-008522
Unity Imaging Center, Radiology. Service 2026-08-04 at outpatient hospital (POS 22). Received 2026-08-10.
Member
Resolved through the identity graph
- Member
- Pamela Yang
- Member ID
- UHC-06553-73
- Date of birth
- 1945-01-06
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-409455
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7329
- Coverage period
- 2024-12-01 to present
- Deductible
- $837.82 of $1,500.0056%
- Out-of-pocket maximum
- $1,338.57 of $3,000.0045%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 8566952718
- Network
- Out of network
- Rendering NPI
- 8566952718
- Location
- Miami, FL · TIN 34-7730969
- Authorisation / referral
- none / REF547017
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 | $246.00 | $110.70 | — | — | DeniedCO204 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $152.00 | $68.40 | — | — | DeniedCO204 |
| Totals | $398.00 | $179.10 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-533406
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006193 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-04: NAVIGATE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 6 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 | Fail | CO204 | Billing provider 8566952718 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Unity Imaging Center2026-08-04 16:01
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
- SystemSystem: Claims system2026-08-10 06:40
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-533406.pdf8 pages
Itemised statement totalling $398.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 8566952718 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000010 | 2026-03-08 | Lakeside Bone and Joint Center | $47,694.00 | Needs review |
| CLM-2026-029003 | 2025-12-14 | Unity Primary Care Associates | $328.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.