CLM-2026-014023
Sunrise Imaging Center, Radiology. Service 2026-07-17 at outpatient hospital (POS 22). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Samantha Guzman
- Member ID
- UHC-92739-37
- Date of birth
- 1969-12-26
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-403704
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-6819
- Coverage period
- 2024-11-01 to present
- Deductible
- $414.62 of $500.0083%
- Out-of-pocket maximum
- $288.76 of $2,000.0014%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9630195771
- Network
- Out of network
- Rendering NPI
- 9630195771
- Location
- Dallas, TX · TIN 60-5457120
- Authorisation / referral
- PA2025759488 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,068.00 | $930.60 | $169.90 | $760.70 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $319.00 | $143.55 | $14.36 | $129.19 | Paid |
| Totals | $2,387.00 | $1,074.15 | $184.26 | $889.89 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-727648
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023571 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-17: N/A (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025759488 on file for 74177. | |
| 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: Sunrise Imaging Center2026-07-17 09:23
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025759488_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-07-17 to 2026-10-15.
- Itemized billitemized_PA-727648.pdf9 pages
Itemised statement totalling $2387.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider 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-2026-026861 | 2026-07-20 | Riverside Digestive Health Center | $310.00 | Denied |
| CLM-2026-026860 | 2026-07-20 | Riverside Digestive Health Center | $310.00 | 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.