CLM-2026-012071
Sunrise Diagnostic Imaging, Radiology. Service 2026-08-04 at outpatient hospital (POS 22). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- Julie Knight
- Member ID
- UHC-71373-79
- Date of birth
- 1989-05-17
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-432262
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1902
- Coverage period
- 2024-04-01 to present
- Deductible
- $816.99 of $3,500.0023%
- Out-of-pocket maximum
- $3,064.77 of $7,000.0044%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 11 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 | $390.00 | $214.50 | $214.50 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $157.00 | $86.35 | $86.35 | $0.00 | Paid |
| Totals | $547.00 | $300.85 | $300.85 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-745479
- 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-009127 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-04: MEDICARE-ADV-B (MA), effective 2024-04-01. | |
| Timely filing | Pass | Received 26 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 Imaging2026-08-04 11:05
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-745479.pdf3 pages
Itemised statement totalling $547.00 across 2 lines.
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-2026-019629 | 2026-01-27 | Pinecrest Bone and Joint Center | $1,453.00 | Needs review |
| CLM-2026-019628 | 2026-01-27 | Pinecrest Bone and Joint Center | $1,453.00 | 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.