CLM-2026-029858
Sunrise Imaging Center, Radiology. Service 2026-04-26 at outpatient hospital (POS 22). Received 2026-06-10.
Member
Resolved through the identity graph
- Member
- Frances Graham
- Member ID
- UHC-93802-82
- Date of birth
- 1971-04-22
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-409823
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7092
- Coverage period
- 2025-07-01 to present
- Deductible
- $1,231.15 of $3,500.0035%
- Out-of-pocket maximum
- $1,196.45 of $14,000.009%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9418627425
- Network
- In network
- Rendering NPI
- 9418627425
- Location
- Mesa, AZ · TIN 78-4773350
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $489.00 | $268.95 | — | — | DeniedCO18 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $209.00 | $114.95 | — | — | DeniedCO18 |
| Totals | $698.00 | $383.90 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-581172
- 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-033925 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-26: CHOICE-PLUS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-029857: 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 Sunrise Imaging Center (9418627425). | |
| 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: Sunrise Imaging Center2026-04-26 16:31
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-10 02:51
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-581172.pdf9 pages
Itemised statement totalling $698.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-029857: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018669 | 2026-08-05 | Cornerstone Reference Lab | $275.00 | Approved |
| CLM-2026-029857 | 2026-04-26 | Sunrise Imaging Center | $698.00 | 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.