CLM-2026-027675
Riverside Imaging Center, Radiology. Service 2026-07-19 at outpatient hospital (POS 22). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Doris Ford
- Member ID
- UHC-97244-05
- Date of birth
- 1958-02-28
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-424926
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2427
- Coverage period
- 2023-03-01 to 2026-01-12
- Deductible
- $299.09 of $500.0060%
- Out-of-pocket maximum
- $664.32 of $1,500.0044%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7550181540
- Network
- In network
- Rendering NPI
- 7550181540
- Location
- Charlotte, NC · TIN 65-3901057
- 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 | $450.00 | $247.50 | — | — | DeniedCO27 |
| Totals | $450.00 | $247.50 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-759447
- 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-012620 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-19 is after coverage terminated on 2026-01-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 | Pass | In-network provider Riverside Imaging Center (7550181540). | |
| 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: Riverside Imaging Center2026-07-19 15:18
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-02 04:32
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-02 09:26
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-759447.pdf2 pages
Itemised statement totalling $450.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-19 is after coverage terminated on 2026-01-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019764 | 2026-03-17 | Mesa Medical Group | $25.00 | Denied |
| CLM-2026-007538 | 2026-01-29 | Lakeside Heart Institute | $1,178.00 | 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.