CLM-2026-028213
Lakeside Imaging Center, Radiology. Service 2026-05-02 at outpatient hospital (POS 22). Received 2026-05-15.
Member
Resolved through the identity graph
- Member
- Bobby Wilson
- Member ID
- UHC-65025-01
- Date of birth
- 1980-12-08
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422482
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1788
- Coverage period
- 2021-08-01 to present
- Deductible
- $702.31 of $2,500.0028%
- Out-of-pocket maximum
- $308.83 of $5,000.006%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 17 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
- PA2026862148 / 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 | $222.00 | $122.10 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 1,2 | $2,851.00 | $1,568.05 | — | — | Review |
| Totals | $3,073.00 | $1,690.15 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-411983
- 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-004716 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-02: SELECT-EPO (EPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026862148 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (2856185642). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Center2026-05-02 09:36
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026862148_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-05-02 to 2026-07-31.
- Itemized billitemized_PA-411983.pdf5 pages
Itemised statement totalling $3073.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031415 | 2026-08-24 | Lakeside Bone and Joint Center | $10,359.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.