CLM-2026-021967
Unity Imaging Center, Radiology. Service 2026-04-23 at outpatient hospital (POS 22). Received 2026-05-12.
Member
Resolved through the identity graph
- Member
- Ann Simpson
- Member ID
- UHC-91154-93
- Date of birth
- 1975-01-13
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-405476
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-1233
- Coverage period
- 2024-05-01 to 2026-03-14
- Deductible
- $1,468.76 of $2,500.0059%
- Out-of-pocket maximum
- $917.76 of $7,500.0012%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 8566952718
- Network
- Out of network
- Rendering NPI
- 8566952718
- Location
- Miami, FL · TIN 34-7730969
- Authorisation / referral
- PA2025325542 / 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 | $3,520.00 | $1,584.00 | — | — | DeniedCO27 |
| Totals | $3,520.00 | $1,584.00 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-178750
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001300 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-23 is after coverage terminated on 2026-03-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025325542 on file for 70553. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Unity Imaging Center2026-04-23 16:13
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-05-12 05:16
Attachments
Documents received with the claim
- Prior auth letterPA2025325542_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-23 to 2026-07-22.
- Itemized billitemized_PA-178750.pdf4 pages
Itemised statement totalling $3520.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-23 is after coverage terminated on 2026-03-14. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.