CLM-2026-015167
Sunrise Diagnostic Imaging, Radiology. Service 2026-05-27 at outpatient hospital (POS 22). Received 2026-06-13.
Member
Resolved through the identity graph
- Member
- Lawrence Russell
- Member ID
- UHC-94134-10
- Date of birth
- 1987-08-05
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-418459
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8287
- Coverage period
- 2021-04-01 to present
- Deductible
- $298.22 of $1,500.0020%
- Out-of-pocket maximum
- $1,833.28 of $6,000.0031%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8125654300
- Network
- In network
- Rendering NPI
- 8125654300
- Location
- Scottsdale, AZ · TIN 88-4094032
- Authorisation / referral
- PA2026325317 / REF375252
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 | $1,840.00 | $1,012.00 | $1,012.00 | $0.00 | Paid |
| Totals | $1,840.00 | $1,012.00 | $1,012.00 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-965005
- 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-020276 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-27: CORE-HMO (HMO), effective 2021-04-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026325317 on file for 70553. | |
| Provider network | Pass | In-network provider Sunrise Diagnostic Imaging (8125654300). | |
| 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 Diagnostic Imaging2026-05-27 17:08
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026325317_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-05-27 to 2026-08-25.
- Itemized billitemized_PA-965005.pdf4 pages
Itemised statement totalling $1840.00 across 1 line.
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-2026-011318 | 2026-09-26 | Pinecrest Primary Care Associates | $313.00 | Approved |
| CLM-2026-030964 | 2026-02-21 | Harbor Regional Medical Center | $2,932.00 | 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.