CLM-2026-020849
Riverside Imaging Center, Radiology. Service 2026-01-01 at outpatient hospital (POS 22). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Charlotte Ortiz
- Member ID
- UHC-52389-49
- Date of birth
- 2002-10-16
- Identity
- Verified6 records, confidence 0.98
- Claim record
- CLMCLM-400267
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7783
- Coverage period
- 2024-12-01 to present
- Deductible
- $93.78 of $2,500.004%
- Out-of-pocket maximum
- $1,262.31 of $10,000.0013%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7427092680
- Network
- In network
- Rendering NPI
- 7427092680
- Location
- Mesa, AZ · TIN 33-8428995
- Authorisation / referral
- PA2026974650 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,250.00 | $1,237.50 | $1,237.50 | $0.00 | Paid |
| Totals | $2,250.00 | $1,237.50 | $1,237.50 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-663437
- 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-001356 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-01-01: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026974650 on file for 70553. | |
| Provider network | Pass | In-network provider Riverside Imaging Center (7427092680). | |
| 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 Center2026-01-01 12:22
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026974650_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-01 to 2026-04-01.
- Itemized billitemized_PA-663437.pdf2 pages
Itemised statement totalling $2250.00 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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022834 | 2026-09-27 | Mesa Medical Group | $272.00 | Denied |
| CLM-2026-022833 | 2026-09-27 | Mesa Medical Group | $272.00 | Approved |
| CLM-2026-016449 | 2026-07-18 | Canyon Primary Care Associates | $335.00 | Approved |
| CLM-2026-031922 | 2026-03-15 | Desert Primary Care Associates | $61.00 | 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.