CLM-2026-008917
Sunrise Imaging Center, Radiology. Service 2026-06-08 at outpatient hospital (POS 22). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Karen Fisehr
- Member ID
- UHC-80767-69
- Date of birth
- 1987-06-18
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-428224
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group NULL
- Coverage period
- 2024-09-01 to present
- Deductible
- $215.66 of $500.0043%
- Out-of-pocket maximum
- $308.55 of $2,000.0015%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9630195771
- Network
- Out of network
- Rendering NPI
- 9630195771
- Location
- Dallas, TX · TIN 60-5457120
- Authorisation / referral
- none / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $138.00 | $62.10 | $62.10 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1,2 | $482.00 | $216.90 | $216.90 | $0.00 | Paid |
| Totals | $620.00 | $279.00 | $279.00 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-747062
- 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-023084 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-08: CHOICE-PLUS-PPO (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 30 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Sunrise Imaging Center2026-06-08 15:19
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-747062.pdf5 pages
Itemised statement totalling $620.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014378 | 2026-03-11 | Riverside Community Hospital | $2,553.00 | 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.