CLM-2026-028416
Unity Imaging Center, Radiology. Service 2026-03-15 at outpatient hospital (POS 22). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Amy Gonzaales
- Member ID
- UHC-79045-67
- Date of birth
- 1969-01-15
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-419847
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7977
- Coverage period
- 2025-06-01 to 2026-01-04
- Deductible
- $531.79 of $1,500.0035%
- Out-of-pocket maximum
- $930.57 of $3,000.0031%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 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 | $169.00 | $76.05 | — | — | DeniedCO27 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $390.00 | $175.50 | — | — | DeniedCO27 |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $473.00 | $212.85 | — | — | DeniedCO27 |
| Totals | $1,032.00 | $464.40 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-162971
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023094 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-15 is after coverage terminated on 2026-01-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 15 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Center2026-03-15 13:22
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-03-30 04:29
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-30 09:09
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-162971.pdf8 pages
Itemised statement totalling $1032.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-15 is after coverage terminated on 2026-01-04. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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.