CLM-2026-022005
Sunrise Imaging Center, Radiology. Service 2026-03-03 at outpatient hospital (POS 22). Received 2026-03-09.
Member
Resolved through the identity graph
- Member
- Jacob Alvarez
- Member ID
- UHC-93064-17
- Date of birth
- 1972-05-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408691
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0998
- Coverage period
- 2023-02-01 to present
- Deductible
- $756.26 of $1,000.0076%
- Out-of-pocket maximum
- $8.34 of $4,000.000%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9630195771
- Network
- Out of network
- Rendering NPI
- 9630195771
- Location
- Dallas, TX · TIN 60-5457120
- Authorisation / referral
- PA2026553327 / 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 | $2,019.00 | $908.55 | — | — | DeniedCO204 |
| Totals | $2,019.00 | $908.55 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-463275
- 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-018440 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-03: SELECT-EPO (EPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026553327 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 9630195771 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Center2026-03-03 14:35
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-09 01:31
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-09 12:22
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026553327_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-03-03 to 2026-06-01.
- Itemized billitemized_PA-463275.pdf7 pages
Itemised statement totalling $2019.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 9630195771 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025521 | 2026-05-04 | Valley Digestive Health Center | $2,490.00 | Needs review |
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
No out-of-network benefit on this plan.