CLM-2026-028735
Lakeside Imaging Center, Radiology. Service 2026-09-03 at outpatient hospital (POS 22). Received 2026-09-07.
Member
Resolved through the identity graph
- Member
- Jesse Hernandez
- Member ID
- UHC-29195-03
- Date of birth
- 1989-02-19
- Identity
- Verified6 records, confidence 0.94
- Claim record
- CLMCLM-404728
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5518
- Coverage period
- 2023-12-01 to 2026-08-22
- Deductible
- $603.66 of $1,000.0060%
- Out-of-pocket maximum
- $549.81 of $3,000.0018%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3836779710
- Network
- In network
- Rendering NPI
- 3836779710
- Location
- Nashville, TN · TIN 29-1460766
- Authorisation / referral
- PA2025387536 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,360.00 | $1,298.00 | — | — | DeniedCO27 |
| Totals | $2,360.00 | $1,298.00 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-472724
- 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-017638 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-03 is after coverage terminated on 2026-08-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025387536 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (3836779710). | |
| 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 Center2026-09-03 10:06
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-09-07 06:14
Attachments
Documents received with the claim
- Prior auth letterPA2025387536_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-03 to 2026-12-02.
- Itemized billitemized_PA-472724.pdf3 pages
Itemised statement totalling $2360.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-03 is after coverage terminated on 2026-08-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014139 | 2026-08-29 | Northgate Counseling Center | $291.00 | Denied |
| CLM-2026-001618 | 2026-06-07 | Unity Primary Care Associates | $458.00 | Approved |
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.