CLM-2026-021372
Sunrise Imaging Center, Radiology. Service 2026-04-10 at outpatient hospital (POS 22). Received 2026-05-25.
Member
Resolved through the identity graph
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5020
- Coverage period
- 2021-01-01 to present
- Deductible
- $32.42 of $1,000.003%
- Out-of-pocket maximum
- $1,444.54 of $3,000.0048%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 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
- PA2025184619 / 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 | $317.00 | $174.35 | — | — | PendedCO16 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,049.00 | $1,126.95 | — | — | PendedCO16 |
| Totals | $2,366.00 | $1,301.30 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-836385
- 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 | Fail | CO16 | Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication |
| Eligibility | Pass | Active on 2026-04-10: OPTIONS-PPO (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025184619 on file for 74177. | |
| 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 Center2026-04-10 13:11
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025184619_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-04-10 to 2026-07-09.
- Itemized billitemized_PA-836385.pdf7 pages
Itemised statement totalling $2366.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Claim record is not attached to a resolved identity.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.