CLM-2026-028892
Riverside Imaging Center, Radiology. Service 2026-03-04 at outpatient hospital (POS 22). Received 2026-04-16.
Member
Resolved through the identity graph
- Member
- Albert Hayes
- Member ID
- UHC-37155-48
- Date of birth
- 1993-09-23
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-413374
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group NULL
- Coverage period
- 2021-12-01 to present
- Deductible
- $1,072.14 of $3,500.0031%
- Out-of-pocket maximum
- $1,748.91 of $10,500.0017%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7427092680
- Network
- In network
- Rendering NPI
- 7427092680
- Location
- Mesa, AZ · TIN 33-8428995
- 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 | $304.00 | $167.20 | — | — | DeniedCO18 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $205.00 | $112.75 | — | — | DeniedCO18 |
| Totals | $509.00 | $279.95 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-937055
- 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-019618 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-04: UNKNOWN (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-028891: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Imaging Center (7427092680). | |
| 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 Center2026-03-04 10:17
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-16 03:51
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-16 17:56
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-937055.pdf7 pages
Itemised statement totalling $509.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-028891: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028891 | 2026-03-04 | Riverside Imaging Center | $509.00 | 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
Exact duplicate of an earlier submission.