CLM-2026-020480
Unity Imaging Center, Radiology. Service 2025-12-22 at outpatient hospital (POS 22). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Alice Ortiz
- Member ID
- UHC-15710-14
- Date of birth
- 1971-04-13
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431267
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4059
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,899.62 of $3,500.0054%
- Out-of-pocket maximum
- $2,465.43 of $7,000.0035%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 3 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $416.00 | $187.20 | $187.20 | $0.00 | Paid |
| Totals | $416.00 | $187.20 | $187.20 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-669916
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000574 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-22: MEDICARE-ADV-A (MA), effective 2022-02-01. | |
| Timely filing | Pass | Received 11 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 Center2025-12-22 13:56
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-669916.pdf9 pages
Itemised statement totalling $416.00 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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004737 | 2026-06-08 | Meadow Primary Care Associates | $306.00 | Approved |
| CLM-2026-007436 | 2026-04-04 | Sunrise Diabetes Center | $45.00 | 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.