CLM-2026-024394
Unity Imaging Center, Radiology. Service 2026-01-03 at outpatient hospital (POS 22). Received 2026-02-04.
Member
Resolved through the identity graph
- Member
- Frank Rian
- Member ID
- UHC-85887-81
- Date of birth
- 1959-12-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407572
- Relationship
- Child, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group N/A
- Coverage period
- 2023-08-01 to present
- Deductible
- $86.89 of $500.0017%
- Out-of-pocket maximum
- $286.00 of $1,000.0029%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 8566952718
- Network
- Out of network
- Rendering NPI
- 8566952718
- Location
- Miami, FL · TIN 34-7730969
- Authorisation / referral
- PA2025770566 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $400.00 | $180.00 | $180.00 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $234.00 | $105.30 | $105.30 | $0.00 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,628.00 | $1,182.60 | $444.25 | $738.35 | Paid |
| Totals | $3,262.00 | $1,467.90 | $729.55 | $738.35 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-833223
- 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-010418 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-03: MEDICARE-ADV-A (MA), effective 2023-08-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025770566 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: Unity Imaging Center2026-01-03 14:57
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025770566_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-01-03 to 2026-04-03.
- Itemized billitemized_PA-833223.pdf6 pages
Itemised statement totalling $3262.00 across 3 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.