CLM-2026-021337
Sunrise Imaging Center, Radiology. Service 2026-09-23 at outpatient hospital (POS 22). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Nicole Watkins
- Member ID
- UHC-16399-53
- Date of birth
- 1971-06-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-418882
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7611
- Coverage period
- 2023-05-01 to 2026-05-14
- Deductible
- $280.70 of $500.0056%
- Out-of-pocket maximum
- $284.33 of $1,000.0028%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9418627425
- Network
- In network
- Rendering NPI
- 9418627425
- Location
- Mesa, AZ · TIN 78-4773350
- Authorisation / referral
- PA2025907023 / 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 | $2,968.00 | $1,632.40 | — | — | DeniedCO27 |
| Totals | $2,968.00 | $1,632.40 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-914789
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016731 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-23 is after coverage terminated on 2026-05-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025907023 on file for 70553. | |
| Provider network | Pass | In-network provider Sunrise Imaging Center (9418627425). | |
| 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 Center2026-09-23 17:57
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-05 06:49
Attachments
Documents received with the claim
- Prior auth letterPA2025907023_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-23 to 2026-12-22.
- Itemized billitemized_PA-914789.pdf6 pages
Itemised statement totalling $2968.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-09-23 is after coverage terminated on 2026-05-14.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.