CLM-2026-022191
Riverside Imaging Center, Radiology. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-02-17.
Member
Resolved through the identity graph
- Member
- Jesse Pena
- Member ID
- UHC-04366-25
- Date of birth
- 1965-01-14
- Identity
- Verified4 records, confidence 0.91
- Claim record
- CLMCLM-411999
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3812
- Coverage period
- 2021-09-01 to present
- Deductible
- $183.54 of $1,500.0012%
- Out-of-pocket maximum
- $1,078.68 of $3,000.0036%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7550181540
- Network
- In network
- Rendering NPI
- 7550181540
- Location
- Charlotte, NC · TIN 65-3901057
- Authorisation / referral
- none / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $132.00 | $72.60 | $72.60 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $356.00 | $195.80 | $195.80 | $0.00 | Paid |
| Totals | $488.00 | $268.40 | $268.40 | $0.00 | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-308153
- 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-013722 (verified, link confidence 0.91). | |
| Eligibility | Pass | Active on 2026-01-08: SELECT-EPO (EPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 40 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 Riverside Imaging Center (7550181540). | |
| 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: Riverside Imaging Center2026-01-08 12:07
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Itemized billitemized_PA-308153.pdf5 pages
Itemised statement totalling $488.00 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-2026-011390 | 2026-04-05 | Riverside Digestive Health Center | $1,999.00 | Needs review |
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.