CLM-2026-013417
Unity Imaging Center, Radiology. Service 2026-08-16 at outpatient hospital (POS 22). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- John Cunningham
- Member ID
- UHC-37758-42
- Date of birth
- 1954-02-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-400218
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3664
- Coverage period
- 2021-08-01 to present
- Deductible
- $357.22 of $2,500.0014%
- Out-of-pocket maximum
- $101.21 of $5,000.002%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 8566952718
- Network
- Out of network
- Rendering NPI
- 8566952718
- Location
- Miami, FL · TIN 34-7730969
- Authorisation / referral
- PA2026740443 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,471.00 | $1,111.95 | — | — | PendedIDQ |
| Totals | $2,471.00 | $1,111.95 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-729191
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001789; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-08-16: UNKNOWN (PPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 57 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-013416; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | Authorisation PA2026740443 on file for 70553. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Imaging Center2026-08-16 17:51
Patient seen for unspecified abdominal pain. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-10-12 04:55
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-12 14:26
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026740443_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-16 to 2026-11-14.
- Itemized billitemized_PA-729191.pdf5 pages
Itemised statement totalling $2471.00 across 1 line.
- Corrected claimcorrected_CLM-2026-013416.pdf1 page
Provider cover letter requesting replacement of CLM-2026-013416.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001789; payment withheld until the identity is confirmed. Replacement claim: Frequency code 7 replaces CLM-2026-013416; the original must be voided when this adjudicates. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013416 | 2026-08-16 | Unity Imaging Center | $2,471.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.