CLM-2026-023125
Summit Imaging Center, Radiology. Service 2026-01-31 at outpatient hospital (POS 22). Received 2026-02-19.
Member
Resolved through the identity graph
- Member
- Jesse Gardner
- Member ID
- UHC-82310-03
- Date of birth
- 1984-12-15
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-404757
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group UNKNOWN
- Coverage period
- 2022-01-01 to 2026-06-12
- Deductible
- $73.55 of $500.0015%
- Out-of-pocket maximum
- $358.28 of $2,000.0018%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4562878908
- Network
- In network
- Rendering NPI
- 4562878908
- Location
- Minneapolis, MN · TIN 57-8653616
- 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 | $225.00 | $123.75 | $123.75 | $0.00 | Paid |
| Totals | $225.00 | $123.75 | $123.75 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-809799
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014411 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-01-31: SELECT-EPO (EPO), effective 2022-01-01, terms 2026-06-12. | |
| Timely filing | Pass | Received 19 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 Summit Imaging Center (4562878908). | |
| 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: Summit Imaging Center2026-01-31 09:51
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-809799.pdf9 pages
Itemised statement totalling $225.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008787 | 2026-08-23 | Riverside GI Associates | $4,411.00 | 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.