CLM-2026-012588
Unity Diagnostic Imaging, Radiology. Service 2025-12-19 at outpatient hospital (POS 22). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Wayne Santos
- Member ID
- UHC-74830-37
- Date of birth
- 1967-08-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406001
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1031
- Coverage period
- 2021-04-01 to 2026-01-03
- Deductible
- $501.52 of $1,000.0050%
- Out-of-pocket maximum
- $84.52 of $3,000.003%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1910682917
- Network
- In network
- Rendering NPI
- 1910682917
- Location
- Mesa, AZ · TIN 81-0269629
- 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 | $341.00 | $187.55 | $187.55 | $0.00 | Paid |
| Totals | $341.00 | $187.55 | $187.55 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-925326
- 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-001573 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-19: SELECT-EPO (EPO), effective 2021-04-01, terms 2026-01-03. | |
| Timely filing | Pass | Received 17 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 Unity Diagnostic Imaging (1910682917). | |
| 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: Unity Diagnostic Imaging2025-12-19 18:31
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-925326.pdf7 pages
Itemised statement totalling $341.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016945 | 2026-05-30 | Pinecrest Primary Care Associates | $309.00 | Denied |
| CLM-2026-029379 | 2026-04-15 | Meadow Primary Care Associates | $497.00 | Denied |
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.