CLM-2026-013605
Sunrise Imaging Center, Radiology. Service 2026-01-31 at outpatient hospital (POS 22). Received 2026-07-03.
Member
Resolved through the identity graph
- Member
- Justin Rice
- Member ID
- UHC-64295-91
- Date of birth
- 1948-06-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428996
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9645
- Coverage period
- 2022-04-01 to 2026-06-02
- Deductible
- $975.87 of $2,500.0039%
- Out-of-pocket maximum
- $4,115.75 of $10,000.0041%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9418627425
- Network
- In network
- Rendering NPI
- 9418627425
- Location
- Mesa, AZ · TIN 78-4773350
- 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 | $349.00 | $191.95 | — | — | DeniedCO29 |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $336.00 | $184.80 | — | — | DeniedCO29 |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $221.00 | $121.55 | — | — | DeniedCO29 |
| Totals | $906.00 | $498.30 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-263875
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023042 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-31: N/A (PPO), effective 2022-04-01, terms 2026-06-02. | |
| Timely filing | Fail | CO29 | Received 153 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Imaging Center (9418627425). | |
| 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 Imaging Center2026-01-31 15:22
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-03 05:17
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-03 11:39
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-263875.pdf6 pages
Itemised statement totalling $906.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 153 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.