CLM-2026-028040
Unity Imaging Center, Radiology. Service 2026-04-26 at outpatient hospital (POS 22). Received 2026-06-10.
Member
Resolved through the identity graph
- Member
- Justin Snyder
- Member ID
- UHC-15556-78
- Date of birth
- 1941-02-25
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-414430
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4887
- Coverage period
- 2023-12-01 to present
- Deductible
- $1,880.98 of $3,500.0054%
- Out-of-pocket maximum
- $95.35 of $14,000.001%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 22 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $197.00 | $88.65 | — | — | DeniedCO204 |
| Totals | $197.00 | $88.65 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-826742
- 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-004064 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-26: SELECT-EPO (EPO), effective 2023-12-01. | |
| 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 | Fail | CO204 | Billing provider 8566952718 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Center2026-04-26 09:18
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
- SystemSystem: Claims system2026-06-10 02:50
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-826742.pdf8 pages
Itemised statement totalling $197.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 8566952718 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019789 | 2026-09-04 | Evergreen Clinical Laboratories | $41.00 | Needs review |
| CLM-2026-019788 | 2026-09-04 | Canyon Reference Lab | $41.00 | Approved |
| CLM-2026-005820 | 2026-03-01 | Unity Bone and Joint Center | $195.00 | Approved |
| CLM-2026-000018 | 2025-12-17 | Lakeside Physical Therapy | $156.00 | 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
No out-of-network benefit on this plan.