CLM-2026-027993
Riverside Imaging Center, Radiology. Service 2026-02-13 at outpatient hospital (POS 22). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Debra Nelson
- Member ID
- UHC-84410-57
- Date of birth
- 1945-02-26
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-431131
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1892
- Coverage period
- 2023-11-01 to present
- Deductible
- $935.30 of $1,500.0062%
- Out-of-pocket maximum
- $94.81 of $4,500.002%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 4 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $259.00 | $142.45 | $142.45 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1 | $211.00 | $116.05 | $116.05 | $0.00 | Paid |
| Totals | $470.00 | $258.50 | $258.50 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- Patient account
- PA-375236
- 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-023023 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-13: MEDICARE-ADV-B (MA), effective 2023-11-01. | |
| 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 Center2026-02-13 12:59
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-375236.pdf3 pages
Itemised statement totalling $470.00 across 2 lines.
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
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.