CLM-2026-025091
Lakeside Imaging Center, Radiology. Service 2026-01-20 at outpatient hospital (POS 22). Received 2026-02-08.
Member
Resolved through the identity graph
- Member
- Diana Perkins
- Member ID
- UHC-40992-46
- Date of birth
- 1972-04-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-423235
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3048
- Coverage period
- 2023-04-01 to present
- Deductible
- $259.03 of $500.0052%
- Out-of-pocket maximum
- $155.37 of $1,500.0010%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 2856185642
- Network
- In network
- Rendering NPI
- 2856185642
- Location
- Miami, FL · TIN 71-0753822
- Authorisation / referral
- PA2026932030 / 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $283.00 | $155.65 | $155.65 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 1 | $1,455.00 | $800.25 | $228.31 | $571.94 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $628.00 | $345.40 | $69.08 | $276.32 | Paid |
| Totals | $2,366.00 | $1,301.30 | $453.04 | $848.26 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-385687
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011419 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-20: MEDICARE-ADV-A (MA), effective 2023-04-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026932030 on file for 74177. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (2856185642). | |
| 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: Lakeside Imaging Center2026-01-20 18:53
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026932030_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-01-20 to 2026-04-20.
- Itemized billitemized_PA-385687.pdf8 pages
Itemised statement totalling $2366.00 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 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031213 | 2026-02-11 | Summit Primary Care Associates | $179.00 | 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.