CLM-2026-020143
Riverside Imaging Center, Radiology. Service 2026-06-04 at outpatient hospital (POS 22). Received 2026-06-18.
Member
Resolved through the identity graph
- Member
- Justin Ortiz
- Member ID
- UHC-24168-07
- Date of birth
- 1956-12-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400961
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8488
- Coverage period
- 2023-01-01 to present
- Deductible
- $142.76 of $500.0029%
- Out-of-pocket maximum
- $261.24 of $1,000.0026%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7550181540
- Network
- In network
- Rendering NPI
- 7550181540
- Location
- Charlotte, NC · TIN 65-3901057
- Authorisation / referral
- none / REF142539
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 | $364.00 | $200.20 | $200.20 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $272.00 | $149.60 | $149.60 | $0.00 | Paid |
| Totals | $636.00 | $349.80 | $349.80 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-119725
- 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-018971 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-04: NAVIGATE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 14 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 Riverside Imaging Center (7550181540). | |
| 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 Center2026-06-04 17:18
Patient seen for pain in right knee. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-18 03:36
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-119725.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-119725.pdf6 pages
Itemised statement totalling $636.00 across 2 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
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
Authorisation must be confirmed with UM before payment.