CLM-2026-024949
Unity Diagnostic Imaging, Radiology. Service 2026-09-01 at outpatient hospital (POS 22). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Samuel Lynch
- Member ID
- UHC-18157-27
- Date of birth
- 1981-12-12
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-413159
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6261
- Coverage period
- 2025-07-01 to present
- Deductible
- $634.46 of $2,500.0025%
- Out-of-pocket maximum
- $84.62 of $5,000.002%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1910682917
- Network
- In network
- Rendering NPI
- 1910682917
- Location
- Mesa, AZ · TIN 81-0269629
- Authorisation / referral
- PA2026125077 / REF426824
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 | $3,558.00 | $1,956.90 | $1,883.81 | $73.09 | Paid |
| Totals | $3,558.00 | $1,956.90 | $1,883.81 | $73.09 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-970863
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001753 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-01: CORE-HMO (HMO), effective 2025-07-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026125077 on file for 70553. | |
| Provider network | Pass | In-network provider Unity Diagnostic Imaging (1910682917). | |
| 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 Diagnostic Imaging2026-09-01 10:01
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Prior auth letterPA2026125077_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-01 to 2026-11-30.
- Itemized billitemized_PA-970863.pdf3 pages
Itemised statement totalling $3558.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005689 | 2026-09-02 | Lakeside Internal Medicine Associates | $68.00 | Approved |
| CLM-2026-017813 | 2026-05-25 | Riverside Orthopedic Specialists | $381.00 | Needs review |
| CLM-2026-017812 | 2026-05-25 | Riverside Orthopedic Specialists | $381.00 | Approved |
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.