CLM-2026-022469
Sunrise Imaging Center, Radiology. Service 2026-05-24 at outpatient hospital (POS 22). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Scott Reed
- Member ID
- UHC-10537-89
- Date of birth
- 1984-08-28
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-415882
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group NULL
- Coverage period
- 2023-08-01 to present
- Deductible
- $127.57 of $2,500.005%
- Out-of-pocket maximum
- $564.62 of $5,000.0011%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 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
- PA2025260674 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,408.00 | $774.40 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $176.00 | $96.80 | — | — | Review |
| Totals | $1,584.00 | $871.20 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-594928
- 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-002288 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-24: MEDICARE-ADV-B (MA), effective 2023-08-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025260674 on file for 74177. | |
| Provider network | Pass | In-network provider Sunrise Imaging Center (4303980450). | |
| Medical necessity | Review | CO50 | 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Center2026-05-24 17:32
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025260674_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-05-24 to 2026-08-22.
- Itemized billitemized_PA-594928.pdf3 pages
Itemised statement totalling $1584.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
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.