CLM-2026-014489
Sunrise Imaging Center, Radiology. Service 2026-07-13 at outpatient hospital (POS 22). Received 2026-07-18.
Member
Resolved through the identity graph
- Member
- Ann Singh
- Member ID
- UHC-68432-82
- Date of birth
- 1944-09-18
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-419804
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9987
- Coverage period
- 2024-07-01 to present
- Deductible
- $2,015.37 of $2,500.0081%
- Out-of-pocket maximum
- $1,094.20 of $7,500.0015%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 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 / REF974691
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 | $2,171.00 | $1,194.05 | — | — | DeniedCO197 |
| Totals | $2,171.00 | $1,194.05 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-934385
- 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-033064 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-13: NAVIGATE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2026-07-13 16:05
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-18 02:47
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-18 11:48
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-934385.pdf7 pages
Itemised statement totalling $2171.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 74177 require precertification; no authorisation number on the claim.
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
Precertification required and absent.