CLM-2026-009177
Sunrise Imaging Center, Radiology. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Brenda Luna
- Member ID
- UHC-89078-96
- Date of birth
- 1985-01-24
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-408197
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9527
- Coverage period
- 2021-06-01 to present
- Deductible
- $325.55 of $1,000.0033%
- Out-of-pocket maximum
- $1,928.02 of $4,000.0048%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9418627425
- Network
- In network
- Rendering NPI
- 9418627425
- Location
- Mesa, AZ · TIN 78-4773350
- Authorisation / referral
- none / REF945060
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 | $348.00 | $191.40 | $191.40 | $0.00 | Paid |
| Totals | $348.00 | $191.40 | $191.40 | $0.00 | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-960710
- 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-005390 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-08: CORE-HMO (HMO), effective 2021-06-01. | |
| Timely filing | Pass | Received 10 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 Sunrise Imaging Center (9418627425). | |
| 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 Center2026-01-08 12:15
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-960710.pdf5 pages
Itemised statement totalling $348.00 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-2026-009178 | 2026-01-08 | Desert Imaging Center | $348.00 | Needs review |
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.