CLM-2026-017452
Sunrise Diagnostic Imaging, Radiology. Service 2026-08-19 at outpatient hospital (POS 22). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Brittany Campbell
- Member ID
- none on golden record
- Date of birth
- 1982-03-19
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417872
- Relationship
- Spouse
Coverage and accumulators
Eligibility
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
- 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 | $258.00 | $141.90 | — | — | PendedN30 |
| Totals | $258.00 | $141.90 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-935121
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-043665 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 20 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 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 | Review | CO16 | Documentation incomplete: “Patient seen for pain in right knee. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Diagnostic Imaging2026-08-19 10:43
Patient seen for pain in right knee. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-08 05:28
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-935121.pdf4 pages
Itemised statement totalling $258.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim. Completeness: Documentation incomplete: “Patient seen for pain in right knee. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.