CLM-2026-026650
Heritage Imaging Center, Radiology. Service 2026-04-25 at outpatient hospital (POS 22). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Rebecca Hart
- Member ID
- UHC-48738-18
- Date of birth
- 1962-03-15
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-415488
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4918
- Coverage period
- 2023-08-01 to present
- Deductible
- $139.01 of $1,000.0014%
- Out-of-pocket maximum
- $569.48 of $2,000.0028%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 15 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 / 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 | $513.00 | $282.15 | — | — | DeniedCO18 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $231.00 | $127.05 | — | — | DeniedCO18 |
| Totals | $744.00 | $409.20 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-244113
- 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-018635 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-25: NULL (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-026649: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Center2026-04-25 11:53
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-04 04:26
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-244113.pdf4 pages
Itemised statement totalling $744.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-026649: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026649 | 2026-04-25 | Heritage Imaging Center | $744.00 | 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
Exact duplicate of an earlier submission.