CLM-2026-027891
Lakeside Imaging Center, Radiology. Service 2026-01-12 at outpatient hospital (POS 22). Received 2026-02-11.
Member
Resolved through the identity graph
- Member
- Lawrence Mitchell
- Member ID
- UHC-30433-13
- Date of birth
- 1940-07-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406503
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8079
- Coverage period
- 2022-11-01 to present
- Deductible
- $1,122.23 of $1,500.0075%
- Out-of-pocket maximum
- $1,431.42 of $3,000.0048%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 2856185642
- Network
- In network
- Rendering NPI
- 2856185642
- Location
- Miami, FL · TIN 71-0753822
- Authorisation / referral
- PA2026326966 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,292.00 | $710.60 | $444.34 | $266.26 | Paid |
| Totals | $1,292.00 | $710.60 | $444.34 | $266.26 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-575647
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012147 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-12: MEDICARE-ADV-A (MA), effective 2022-11-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026326966 on file for 74177. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (2856185642). | |
| 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: Lakeside Imaging Center2026-01-12 09:55
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026326966_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-01-12 to 2026-04-12.
- Itemized billitemized_PA-575647.pdf8 pages
Itemised statement totalling $1292.00 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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029596 | 2026-06-22 | Mesa Internal Medicine Associates | $57.00 | Approved |
| CLM-2026-033493 | 2026-05-20 | Harbor Rehabilitation Center | $86.00 | Needs review |
| CLM-2026-033492 | 2026-05-20 | Harbor Rehabilitation Center | $258.00 | 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.