CLM-2026-014894
Riverside Imaging Center, Radiology. Service 2026-06-07 at outpatient hospital (POS 22). Received 2026-07-17.
Member
Resolved through the identity graph
- Member
- Bobby Adams
- Member ID
- UHC-70130-54
- Date of birth
- 1972-01-12
- Identity
- Verified4 records, confidence 0.92
- Claim record
- CLMCLM-423147
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5295
- Coverage period
- 2024-09-01 to present
- Deductible
- $2,011.21 of $3,500.0057%
- Out-of-pocket maximum
- $2,682.39 of $7,000.0038%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7427092680
- Network
- In network
- Rendering NPI
- 7427092680
- Location
- Mesa, AZ · TIN 33-8428995
- Authorisation / referral
- PA2026228718 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $477.00 | $262.35 | $262.35 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $199.00 | $109.45 | $109.45 | $0.00 | Paid |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,284.00 | $706.20 | $706.20 | $0.00 | Paid |
| Totals | $1,960.00 | $1,078.00 | $1,078.00 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-794275
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006162 (verified, link confidence 0.92). | |
| Eligibility | Pass | Active on 2026-06-07: NULL (PPO), effective 2024-09-01. | |
| 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 PA2026228718 on file for 74177. | |
| Provider network | Pass | In-network provider Riverside Imaging Center (7427092680). | |
| 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: Riverside Imaging Center2026-06-07 09:19
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026228718_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-06-07 to 2026-09-05.
- Itemized billitemized_PA-794275.pdf5 pages
Itemised statement totalling $1960.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006846 | 2025-12-18 | Summit Imaging Center | $1,638.00 | 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.