CLM-2026-024461
Sunrise Diagnostic Imaging, Radiology. Service 2025-12-10 at outpatient hospital (POS 22). Received 2026-01-03.
Member
Resolved through the identity graph
- Member
- Nicole Henderson
- Member ID
- UHC-56732-85
- Date of birth
- 1995-05-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-419194
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0820
- Coverage period
- 2023-10-01 to present
- Deductible
- $449.79 of $500.0090%
- Out-of-pocket maximum
- $212.76 of $2,000.0011%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8125654300
- Network
- In network
- Rendering NPI
- 8125654300
- Location
- Scottsdale, AZ · TIN 88-4094032
- Authorisation / referral
- PA2026676796 / REF332959
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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 59 | 1 | 1 | $2,051.00 | $1,128.05 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | 59 | 1 | 1,2 | $2,827.00 | $1,554.85 | — | — | Review |
| 3 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1,2 | $343.00 | $188.65 | — | — | Review |
| Totals | $5,221.00 | $2,871.55 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R07.9 Chest pain, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-600361
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000861 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-10: NAVIGATE-HMO (HMO), effective 2023-10-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026676796 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Sunrise Diagnostic Imaging (8125654300). | |
| Medical necessity | Review | CO50 | 74177, 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Diagnostic Imaging2025-12-10 15:37
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-03 02:56
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Prior auth letterPA2026676796_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-12-10 to 2026-03-10.
- Itemized billitemized_PA-600361.pdf4 pages
Itemised statement totalling $5221.00 across 3 lines.
- Medical recordrecords_PA-600361.pdf11 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 74177, 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-21 14:05The claim includes services 74177 and 70553 billed with a routine diagnosis Z12.31, which does not support medical necessity [R-clinical_edit]. Additionally, modifier 59 was used on a normally bundled code pair, and the clinical note indicates that both procedures were performed at the same site during the same session [N1], which does not justify the use of modifier 59 [R-ncci].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 0db2ba14
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO50 Not medically necessary per payer policy
- CO97 Benefit included in another service already adjudicated
The claim includes services 74177 and 70553 billed with a routine diagnosis Z12.31, which does not support medical necessity [R-clinical_edit]. Additionally, modifier 59 was used on a normally bundled code pair, and the clinical note indicates that both procedures were performed at the same site during the same session [N1], which does not justify the use of modifier 59 [R-ncci].
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO50 Not medically necessary per payer policy
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.