CLM-2026-023174
Sunrise Imaging Center, Radiology. Service 2026-06-02 at outpatient hospital (POS 22). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Barbara Carter
- Member ID
- UHC-44811-12
- Date of birth
- 1941-08-17
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-415256
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1089
- Coverage period
- 2025-09-01 to present
- Deductible
- $253.44 of $1,000.0025%
- Out-of-pocket maximum
- $298.85 of $4,000.007%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 7 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
- PA2026324389 / 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 | $170.00 | $76.50 | $76.50 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,010.00 | $904.50 | $693.50 | $211.00 | Paid |
| Totals | $2,180.00 | $981.00 | $770.00 | $211.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-789263
- 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-034572 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-02: OPTIONS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026324389 on file for 74177. | |
| 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: Sunrise Imaging Center2026-06-02 09:09
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026324389_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-06-02 to 2026-08-31.
- Itemized billitemized_PA-789263.pdf4 pages
Itemised statement totalling $2180.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider 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
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.