CLM-2026-027786
Sunrise Imaging Center, Radiology. Service 2026-04-21 at outpatient hospital (POS 22). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Abigail Martinez
- Member ID
- UHC-84886-97
- Date of birth
- 1967-03-08
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-410335
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group NULL
- Coverage period
- 2022-03-01 to 2026-03-06
- Deductible
- $72.46 of $500.0014%
- Out-of-pocket maximum
- $189.17 of $2,000.009%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4303980450
- Network
- In network
- Rendering NPI
- 4303980450
- Location
- Miami, FL · TIN 94-2880728
- Authorisation / referral
- none / REF810600
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $145.00 | $79.75 | — | — | DeniedCO27 |
| Totals | $145.00 | $79.75 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-227596
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020768 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-21 is after coverage terminated on 2026-03-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 Sunrise Imaging Center (4303980450). | |
| 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 Imaging Center2026-04-21 16:29
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-26 01:13
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-26 12:20
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-227596.pdf7 pages
Itemised statement totalling $145.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-21 is after coverage terminated on 2026-03-06.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028961 | 2026-02-28 | Heritage Primary Care Associates | $45.00 | 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
Service after coverage termination.