CLM-2026-020893
Sunrise Imaging Center, Radiology. Service 2025-12-20 at outpatient hospital (POS 22). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Nancy Delgado
- Member ID
- UHC-59285-16
- Date of birth
- 1969-01-08
- Identity
- Verified4 records, confidence 0.92
- Claim record
- CLMCLM-401261
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3079
- Coverage period
- 2024-09-01 to present
- Deductible
- $408.37 of $500.0082%
- Out-of-pocket maximum
- $72.16 of $1,000.007%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4303980450
- Network
- In network
- Rendering NPI
- 4303980450
- Location
- Miami, FL · TIN 94-2880728
- 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 | $326.00 | $179.30 | $109.16 | $70.14 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $220.00 | $121.00 | $24.20 | $96.80 | Paid |
| Totals | $546.00 | $300.30 | $133.36 | $166.94 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-408030
- 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-003675 (verified, link confidence 0.92). | |
| Eligibility | Pass | Active on 2025-12-20: MEDICARE-ADV-A (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 23 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 Imaging Center (4303980450). | |
| 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: Sunrise Imaging Center2025-12-20 10:08
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-408030.pdf9 pages
Itemised statement totalling $546.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005168 | 2026-07-10 | Riverside Family Practice | $613.00 | Approved |
| CLM-2026-028722 | 2026-04-25 | Desert Reference Lab | $105.00 | 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.