CLM-2026-017430
Lakeside Imaging Center, Radiology. Service 2026-01-04 at outpatient hospital (POS 22). Received 2026-02-08.
Member
Resolved through the identity graph
- Member
- Diego Espinoza
- Member ID
- UHC-84552-22
- Date of birth
- 2002-04-14
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-421573
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5110
- Coverage period
- 2024-06-01 to present
- Deductible
- $422.69 of $500.0085%
- Out-of-pocket maximum
- $332.29 of $1,000.0033%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4829743648
- Network
- In network
- Rendering NPI
- 4829743648
- Location
- Minneapolis, MN · TIN 87-3632325
- 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 | $355.00 | $195.25 | $112.69 | $82.56 | Paid |
| Totals | $355.00 | $195.25 | $112.69 | $82.56 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-686598
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011465 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-01-04: MEDICARE-ADV-B (MA), effective 2024-06-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (4829743648). | |
| 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: Lakeside Imaging Center2026-01-04 15:39
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-686598.pdf3 pages
Itemised statement totalling $355.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.