CLM-2026-023957
Sunrise Imaging Center, Radiology. Service 2026-08-17 at outpatient hospital (POS 22). Received 2026-09-07.
Member
Resolved through the identity graph
- Member
- Kyle Simpson
- Member ID
- UHC-10810-94
- Date of birth
- 2007-04-15
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-404033
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2294
- Coverage period
- 2021-12-01 to present
- Deductible
- $249.70 of $1,500.0017%
- Out-of-pocket maximum
- $1,993.52 of $6,000.0033%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 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
- PA2025961937 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,813.00 | $1,265.85 | $1,253.41 | $12.44 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $413.00 | $185.85 | $37.17 | $148.68 | Paid |
| Totals | $3,226.00 | $1,451.70 | $1,290.58 | $161.12 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-195910
- 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-027999 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-17: OPTIONS-PPO (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025961937 on file for 70553. | |
| 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 Center2026-08-17 09:07
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025961937_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-17 to 2026-11-15.
- Itemized billitemized_PA-195910.pdf2 pages
Itemised statement totalling $3226.00 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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011773 | 2026-04-05 | Unity Reference Lab | $3,304.00 | Needs review |
| CLM-2026-000292 | 2026-03-14 | Pinecrest Diagnostic Imaging | $1,860.00 | 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.