CLM-2026-021806
Sunrise Diagnostic Imaging, Radiology. Service 2026-01-12 at outpatient hospital (POS 22). Received 2026-01-24.
Member
Resolved through the identity graph
- Member
- Doris Mendez
- Member ID
- UHC-89129-89
- Date of birth
- 1997-11-25
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-431042
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7243
- Coverage period
- 2022-11-01 to 2026-05-13
- Deductible
- $1,726.73 of $2,500.0069%
- Out-of-pocket maximum
- $1,989.35 of $7,500.0027%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8125654300
- Network
- In network
- Rendering NPI
- 8125654300
- Location
- Scottsdale, AZ · TIN 88-4094032
- Authorisation / referral
- none / REF124552
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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $378.00 | $207.90 | $207.90 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $146.00 | $80.30 | $80.30 | $0.00 | Paid |
| Totals | $524.00 | $288.20 | $288.20 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-279697
- 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-007330 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-01-12: NAVIGATE-HMO (HMO), effective 2022-11-01, terms 2026-05-13. | |
| Timely filing | Pass | Received 12 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 Diagnostic Imaging (8125654300). | |
| 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 Diagnostic Imaging2026-01-12 09:59
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-279697.pdf7 pages
Itemised statement totalling $524.00 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-2026-021718 | 2026-06-09 | Evergreen Medical Group | $280.00 | Denied |
| CLM-2026-001861 | 2026-05-10 | Unity Primary Care Associates | $213.00 | 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.