CLM-2026-011031
Heritage Imaging Center, Radiology. Service 2026-10-03 at outpatient hospital (POS 22). Received 2026-10-14.
Member
Resolved through the identity graph
- Member
- Omar Hunt
- Member ID
- UHC-97434-51
- Date of birth
- 1938-05-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-418951
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5175
- Coverage period
- 2021-01-01 to 2026-06-23
- Deductible
- $1,102.82 of $3,500.0032%
- Out-of-pocket maximum
- $2,121.25 of $10,500.0020%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 5 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
- PA2025551308 / REF504439
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 | $611.00 | $336.05 | — | — | DeniedCO27 |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $2,395.00 | $1,317.25 | — | — | DeniedCO27 |
| Totals | $3,006.00 | $1,653.30 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-558293
- 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-002775 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-03 is after coverage terminated on 2026-06-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025551308 on file for 70553. | |
| 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 Center2026-10-03 10:11
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-10-14 03:48
Attachments
Documents received with the claim
- Prior auth letterPA2025551308_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-10-03 to 2027-01-01.
- Itemized billitemized_PA-558293.pdf3 pages
Itemised statement totalling $3006.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-10-03 is after coverage terminated on 2026-06-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018823 | 2026-09-15 | Heritage Rehabilitation Center | $180.00 | Denied |
| CLM-2026-001430 | 2026-07-24 | Valley Heart Institute | $321.00 | Denied |
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.