CLM-2026-009316
Sunrise Imaging Center, Radiology. Service 2026-06-27 at outpatient hospital (POS 22). Received 2026-07-12.
Member
Resolved through the identity graph
- Member
- Lisa Silva
- Member ID
- UHC-88580-44
- Date of birth
- 2002-04-16
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-404537
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4998
- Coverage period
- 2023-10-01 to present
- Deductible
- $903.04 of $1,500.0060%
- Out-of-pocket maximum
- $500.41 of $6,000.008%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
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
- PA2025643500 / REF404346
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 | $2,469.00 | $1,357.95 | — | — | Review |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $524.00 | $288.20 | — | — | Review |
| Totals | $2,993.00 | $1,646.15 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-853939
- 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-012074 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-27: CORE-HMO (HMO), effective 2023-10-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025643500 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 Center2026-06-27 16:34
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025643500_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-06-27 to 2026-09-25.
- Itemized billitemized_PA-853939.pdf9 pages
Itemised statement totalling $2993.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical 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-2026-006233 | 2026-04-07 | Unity Counseling Center | $280.00 | Approved |
| CLM-2026-028433 | 2026-01-27 | Evergreen Dermatology Clinic | $699.00 | Approved |
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.