CLM-2026-026211
Sunrise Imaging Center, Radiology. Service 2026-10-10 at outpatient hospital (POS 22). Received 2026-10-13.
Member
Resolved through the identity graph
- Member
- Judy Wells
- Member ID
- UHC-84471-03
- Date of birth
- 1938-01-11
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-405960
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7168
- Coverage period
- 2025-08-01 to 2026-04-22
- Deductible
- $401.27 of $500.0080%
- Out-of-pocket maximum
- $14.70 of $1,500.001%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 2 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
- PA2025818405 / REF243570
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 | $3,168.00 | $1,742.40 | — | — | DeniedCO27 |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,596.00 | $1,427.80 | — | — | DeniedCO27 |
| Totals | $5,764.00 | $3,170.20 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-430315
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022239 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-10 is after coverage terminated on 2026-04-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025818405 on file for 70553, 74177. | |
| 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 Center2026-10-10 14:06
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-10-13 01:38
Attachments
Documents received with the claim
- Prior auth letterPA2025818405_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-10-10 to 2027-01-08.
- Itemized billitemized_PA-430315.pdf6 pages
Itemised statement totalling $5764.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-10-10 is after coverage terminated on 2026-04-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032216 | 2026-08-12 | Riverside Imaging Center | $721.00 | Denied |
| CLM-2026-010993 | 2026-08-24 | Meadow Family Practice | $703.00 | Denied |
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.