CLM-2026-009611
Heritage Imaging Center, Radiology. Service 2026-04-10 at outpatient hospital (POS 22). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Joan Edwards
- Member ID
- UHC-88614-34
- Date of birth
- 1956-07-06
- Identity
- Verified7 records, confidence 0.98
- Claim record
- CLMCLM-422141
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2620
- Coverage period
- 2022-12-01 to present
- Deductible
- $648.33 of $1,000.0065%
- Out-of-pocket maximum
- $1,815.32 of $4,000.0045%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4466693437
- Network
- In network
- Rendering NPI
- 4466693437
- Location
- Atlanta, GA · TIN 36-7680074
- 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $385.00 | $211.75 | $211.75 | $0.00 | Paid |
| Totals | $385.00 | $211.75 | $211.75 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-525287
- 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-008807 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-04-10: NULL (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 27 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 Heritage Imaging Center (4466693437). | |
| 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: Heritage Imaging Center2026-04-10 14:11
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-525287.pdf3 pages
Itemised statement totalling $385.00 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-2026-012959 | 2026-09-02 | Harbor Medical Group | $651.00 | Needs review |
| CLM-2026-012958 | 2026-09-02 | Harbor Medical Group | $651.00 | Approved |
| CLM-2026-020043 | 2025-12-27 | Mesa Internal Medicine Associates | $187.00 | Denied |
| CLM-2026-009289 | 2026-03-29 | Mesa Clinical Laboratories | $126.00 | Approved |
| CLM-2026-008233 | 2026-05-03 | Lakeside Medical Group | $333.00 | 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.