CLM-2026-009021
Sunrise Imaging Center, Radiology. Service 2026-05-10 at outpatient hospital (POS 22). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Daniel Bailey
- Member ID
- none on golden record
- Date of birth
- 1967-02-12
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-401095
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4303980450
- Network
- In network
- Rendering NPI
- 4303980450
- Location
- Miami, FL · TIN 94-2880728
- Authorisation / referral
- PA2026886983 / 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 | $2,423.00 | $1,332.65 | — | — | PendedN30 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $191.00 | $105.05 | — | — | PendedN30 |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | 25 | 1 | 1 | $543.00 | $298.65 | — | — | PendedN30 |
| Totals | $3,157.00 | $1,736.35 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-839201
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029219 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026886983 on file for 74177. | |
| Provider network | Pass | In-network provider Sunrise Imaging Center (4303980450). | |
| Medical necessity | Review | CO50 | 74177 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 Imaging Center2026-05-10 17:08
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 letterPA2026886983_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-05-10 to 2026-08-08.
- Itemized billitemized_PA-839201.pdf6 pages
Itemised statement totalling $3157.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim. Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024873 | 2026-04-27 | Riverside Regional Medical Center | $2,003.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.