CLM-2026-026935
Sunrise Diagnostic Imaging, Radiology. Service 2026-01-13 at outpatient hospital (POS 22). Received 2026-02-12.
Member
Resolved through the identity graph
- Member
- Christopher Wilson
- Member ID
- UHC-54608-62
- Date of birth
- 1946-12-07
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-429569
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7179
- Coverage period
- 2023-12-01 to present
- Deductible
- $2,153.96 of $3,500.0062%
- Out-of-pocket maximum
- $1,985.93 of $14,000.0014%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8125654300
- Network
- In network
- Rendering NPI
- 8125654300
- Location
- Scottsdale, AZ · TIN 88-4094032
- Authorisation / referral
- none / REF187903
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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,993.00 | $1,096.15 | — | — | DeniedCO197 |
| Totals | $1,993.00 | $1,096.15 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-368430
- 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-011557 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-13: NAVIGATE-HMO (HMO), effective 2023-12-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Sunrise Diagnostic Imaging (8125654300). | |
| 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 Diagnostic Imaging2026-01-13 18:21
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-12 01:27
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-12 17:00
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-368430.pdf8 pages
Itemised statement totalling $1993.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 74177 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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
Precertification required and absent.