CLM-2026-024978
Sunrise Imaging Center, Radiology. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-02-13.
Member
Resolved through the identity graph
- Member
- Joyce Sandoval
- Member ID
- UHC-20229-57
- Date of birth
- 1952-02-20
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-424393
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6268
- Coverage period
- 2024-04-01 to present
- Deductible
- $172.69 of $3,500.005%
- Out-of-pocket maximum
- $3,428.47 of $7,000.0049%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9418627425
- Network
- In network
- Rendering NPI
- 9418627425
- Location
- Mesa, AZ · TIN 78-4773350
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $389.00 | $213.95 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 2 | $200.00 | $110.00 | — | — | Review |
| Totals | $589.00 | $323.95 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-145363
- 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-012898 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-07: OPTIONS-PPO (PPO), effective 2024-04-01. | |
| 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 | Pass | In-network provider Sunrise Imaging Center (9418627425). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Note ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Imaging Center2026-01-07 12:03
Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-13 04:09
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-145363.pdf5 pages
Itemised statement totalling $589.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Note ”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006023 | 2026-06-17 | Mesa Medical Group | $245.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.