CLM-2026-020994
Lakeside Imaging Center, Radiology. Service 2026-01-24 at outpatient hospital (POS 22). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Kyle Phillips
- Member ID
- UHC-66079-97
- Date of birth
- 1999-01-04
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-412945
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4124
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,996.53 of $3,500.0057%
- Out-of-pocket maximum
- $5,022.99 of $14,000.0036%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 2856185642
- Network
- In network
- Rendering NPI
- 2856185642
- Location
- Miami, FL · TIN 71-0753822
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $112.00 | $61.60 | $61.60 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $262.00 | $144.10 | $144.10 | $0.00 | Paid |
| Totals | $374.00 | $205.70 | $205.70 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-657862
- 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-000157 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-24: UNKNOWN (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 29 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 Lakeside Imaging Center (2856185642). | |
| 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: Lakeside Imaging Center2026-01-24 12:03
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-657862.pdf5 pages
Itemised statement totalling $374.00 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-2026-000095 | 2026-07-30 | Desert Internal Medicine Associates | $77.00 | Approved |
| CLM-2026-005155 | 2025-12-26 | Mesa Physical Therapy | $238.00 | Denied |
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.