CLM-2026-026798
Summit Imaging Center, Radiology. Service 2026-06-14 at outpatient hospital (POS 22). Received 2026-06-25.
Member
Resolved through the identity graph
- Member
- Kyle Vega
- Member ID
- UHC-33957-43
- Date of birth
- 1943-01-08
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-408622
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0751
- Coverage period
- 2023-07-01 to present
- Deductible
- $2,534.32 of $3,500.0072%
- Out-of-pocket maximum
- $321.27 of $7,000.005%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4562878908
- Network
- In network
- Rendering NPI
- 4562878908
- Location
- Minneapolis, MN · TIN 57-8653616
- Authorisation / referral
- PA2026542553 / 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 | $381.00 | $209.55 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 1 | $2,700.00 | $1,485.00 | — | — | Review |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $482.00 | $265.10 | — | — | Review |
| Totals | $3,563.00 | $1,959.65 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-464445
- 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-011634 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-14: CHOICE-PLUS-PPO (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026542553 on file for 70553. | |
| Provider network | Pass | In-network provider Summit Imaging Center (4562878908). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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: Summit Imaging Center2026-06-14 11:16
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026542553_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-06-14 to 2026-09-12.
- Itemized billitemized_PA-464445.pdf4 pages
Itemised statement totalling $3563.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003565 | 2026-06-11 | Mesa Family Practice | $457.00 | Approved |
| CLM-2026-005981 | 2026-03-15 | Mesa Medical Group | $243.00 | Approved |
| CLM-2026-024728 | 2026-02-06 | Evergreen Primary Care Associates | $229.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.