CLM-2026-023230
Sunrise Imaging Center, Radiology. Service 2026-01-31 at outpatient hospital (POS 22). Received 2026-03-09.
Member
Resolved through the identity graph
- Member
- Amy Collins
- Member ID
- UHC-11297-50
- Date of birth
- 1970-09-28
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-424581
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1690
- Coverage period
- 2025-06-01 to present
- Deductible
- $40.60 of $2,500.002%
- Out-of-pocket maximum
- $571.70 of $5,000.0011%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 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
- 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 | $227.00 | $102.15 | — | — | DeniedCO204 |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $571.00 | $256.95 | — | — | DeniedCO204 |
| Totals | $798.00 | $359.10 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-422170
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007121 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-31: SELECT-EPO (EPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 37 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 | 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 Center2026-01-31 12:06
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-09 03:16
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 09:54
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-422170.pdf8 pages
Itemised statement totalling $798.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider 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
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.