CLM-2026-026973
Unity Imaging Center, Radiology. Service 2026-02-05 at outpatient hospital (POS 22). Received 2026-03-10.
Member
Resolved through the identity graph
- Member
- Benjamin Cooper
- Member ID
- UHC-69545-33
- Date of birth
- 1968-06-14
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432149
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2790
- Coverage period
- 2023-11-01 to present
- Deductible
- $643.87 of $1,000.0064%
- Out-of-pocket maximum
- $287.99 of $4,000.007%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 8566952718
- Network
- Out of network
- Rendering NPI
- 8566952718
- Location
- Miami, FL · TIN 34-7730969
- 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 | $558.00 | $251.10 | $251.10 | $0.00 | Paid |
| Totals | $558.00 | $251.10 | $251.10 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-130125
- 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-004199 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-05: NULL (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 33 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Unity Imaging Center2026-02-05 15:59
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-130125.pdf3 pages
Itemised statement totalling $558.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017358 | 2026-08-23 | Unity Physical Therapy | $234.00 | Approved |
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.