CLM-2026-020078
Unity Imaging Center, Radiology. Service 2026-03-29 at outpatient hospital (POS 22). Received 2026-05-11.
Member
Resolved through the identity graph
- Member
- Amanda Morris
- Member ID
- UHC-46284-07
- Date of birth
- 1961-07-06
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-405104
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1262
- Coverage period
- 2021-08-01 to present
- Deductible
- $3.69 of $2,500.000%
- Out-of-pocket maximum
- $736.28 of $5,000.0015%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 8566952718
- Network
- Out of network
- Rendering NPI
- 8566952718
- Location
- Miami, FL · TIN 34-7730969
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $500.00 | $225.00 | $225.00 | $0.00 | Paid |
| Totals | $500.00 | $225.00 | $225.00 | $0.00 | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-600999
- 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-030278 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-03-29: NULL (PPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 43 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Unity Imaging Center2026-03-29 18:25
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-600999.pdf5 pages
Itemised statement totalling $500.00 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 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.