CLM-2026-009592
Sunrise Diagnostic Imaging, Radiology. Service 2026-08-09 at outpatient hospital (POS 22). Received 2026-09-13.
Member
Resolved through the identity graph
- Member
- Wei Romero
- Member ID
- UHC-06004-43
- Date of birth
- 1986-01-19
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-414874
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4394
- Coverage period
- 2025-04-01 to 2026-05-27
- Deductible
- $2,833.28 of $3,500.0081%
- Out-of-pocket maximum
- $388.23 of $14,000.003%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8125654300
- Network
- In network
- Rendering NPI
- 8125654300
- Location
- Scottsdale, AZ · TIN 88-4094032
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $527.00 | $289.85 | — | — | DeniedCO27 |
| Totals | $527.00 | $289.85 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- 3. R51.9 Headache, unspecified
- Patient account
- PA-278069
- 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-021169 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-09 is after coverage terminated on 2026-05-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 Diagnostic Imaging (8125654300). | |
| 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 Diagnostic Imaging2026-08-09 18:55
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-09-13 03:06
Attachments
Documents received with the claim
- Itemized billitemized_PA-278069.pdf2 pages
Itemised statement totalling $527.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-09 is after coverage terminated on 2026-05-27.
Other claims for this member
Same resolved identity
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
Service after coverage termination.