CLM-2026-025668
Heritage Imaging Center, Radiology. Service 2026-08-12 at outpatient hospital (POS 22). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Samuel Richardson
- Member ID
- UHC-82787-14
- Date of birth
- 2000-08-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-427610
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5073
- Coverage period
- 2023-10-01 to present
- Deductible
- $413.44 of $500.0083%
- Out-of-pocket maximum
- $305.85 of $1,000.0031%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4466693437
- Network
- In network
- Rendering NPI
- 4466693437
- Location
- Atlanta, GA · TIN 36-7680074
- Authorisation / referral
- none / REF601065
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $205.00 | $112.75 | $94.42 | $18.33 | Paid |
| Totals | $205.00 | $112.75 | $94.42 | $18.33 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-983025
- 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-034182 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-12: CORE-HMO (HMO), effective 2023-10-01. | |
| Timely filing | Pass | Received 21 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 Heritage Imaging Center (4466693437). | |
| 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: Heritage Imaging Center2026-08-12 12:37
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-983025.pdf3 pages
Itemised statement totalling $205.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.