CLM-2026-011935
Lakeside Imaging Center, Radiology. Service 2026-08-19 at outpatient hospital (POS 22). Received 2026-09-07.
Member
Resolved through the identity graph
- Member
- Theresa Parker
- Member ID
- UHC-81599-10
- Date of birth
- 1990-10-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413074
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group -
- Coverage period
- 2022-05-01 to present
- Deductible
- $2,693.29 of $3,500.0077%
- Out-of-pocket maximum
- $887.23 of $7,000.0013%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 2856185642
- Network
- In network
- Rendering NPI
- 2856185642
- Location
- Miami, FL · TIN 71-0753822
- Authorisation / referral
- PA2026541216 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $173.00 | $95.15 | $95.15 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $1,940.00 | $1,067.00 | $782.65 | $284.35 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $349.00 | $191.95 | $38.39 | $153.56 | Paid |
| Totals | $2,462.00 | $1,354.10 | $916.19 | $437.91 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-844526
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-034749 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-19: CHOICE-PLUS-PPO (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026541216 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (2856185642). | |
| 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: Lakeside Imaging Center2026-08-19 10:12
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Prior auth letterPA2026541216_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-08-19 to 2026-11-17.
- Itemized billitemized_PA-844526.pdf7 pages
Itemised statement totalling $2462.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.