CLM-2026-025371
Sunrise Imaging Center, Radiology. Service 2026-05-01 at outpatient hospital (POS 22). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Eric Castro
- Member ID
- UHC-08239-66
- Date of birth
- 1968-04-02
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-408474
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8348
- Coverage period
- 2023-10-01 to 2026-04-20
- Deductible
- $1,515.32 of $2,500.0061%
- Out-of-pocket maximum
- $3,233.62 of $7,500.0043%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 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 / REF469718
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 | $410.00 | $225.50 | — | — | DeniedCO27 |
| Totals | $410.00 | $225.50 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-107335
- 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-004267 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-01 is after coverage terminated on 2026-04-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 32 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Imaging Center2026-05-01 14:15
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-02 06:54
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-02 15:32
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-107335.pdf5 pages
Itemised statement totalling $410.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-01 is after coverage terminated on 2026-04-20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033432 | 2026-04-28 | Pinecrest Clinical Laboratories | $124.00 | Denied |
| CLM-2026-015676 | 2026-03-07 | Desert Internal Medicine Associates | $323.00 | Approved |
| CLM-2026-030356 | 2025-12-28 | Riverside Digestive Health Center | $2,012.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.