CLM-2026-012167
Lakeside Imaging Center, Radiology. Service 2026-10-04 at outpatient hospital (POS 22). Received 2026-10-13.
Member
Resolved through the identity graph
- Member
- Debra Elliott
- Member ID
- UHC-29655-41
- Date of birth
- 1959-08-05
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-414095
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8732
- Coverage period
- 2025-11-01 to present
- Deductible
- $1,337.13 of $3,500.0038%
- Out-of-pocket maximum
- $2,565.20 of $10,500.0024%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4829743648
- Network
- In network
- Rendering NPI
- 4829743648
- Location
- Minneapolis, MN · TIN 87-3632325
- 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 | $562.00 | $309.10 | $309.10 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | 25 | 1 | 1,2 | $302.00 | $166.10 | $166.10 | $0.00 | Paid |
| Totals | $864.00 | $475.20 | $475.20 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-634839
- 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-013297 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-10-04: OPTIONS-PPO (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 9 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 Lakeside Imaging Center (4829743648). | |
| 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 Center2026-10-04 16:02
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-634839.pdf3 pages
Itemised statement totalling $864.00 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-2026-013570 | 2026-09-02 | Lakeside Internal Medicine Associates | $288.00 | Needs review |
| CLM-2026-024843 | 2026-07-05 | Harbor Primary Care Associates | $231.00 | 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.