CLM-2026-030862
Sunrise Imaging Center, Radiology. Service 2026-03-25 at outpatient hospital (POS 22). Received 2026-04-13.
Member
Resolved through the identity graph
- Member
- Charlotte Welch
- Member ID
- UHC-68577-02
- Date of birth
- 1957-01-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-407965
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1205
- Coverage period
- 2023-12-01 to present
- Deductible
- $1,703.79 of $3,500.0049%
- Out-of-pocket maximum
- $6,908.24 of $14,000.0049%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 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
- PA2026333905 / 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 | $370.00 | $203.50 | $203.50 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $366.00 | $201.30 | $201.30 | $0.00 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,428.00 | $1,885.40 | $1,490.21 | $395.19 | Paid |
| Totals | $4,164.00 | $2,290.20 | $1,895.01 | $395.19 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-131333
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008617 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-25: NULL (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026333905 on file for 70553. | |
| 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 Center2026-03-25 11:51
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026333905_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-03-25 to 2026-06-23.
- Itemized billitemized_PA-131333.pdf3 pages
Itemised statement totalling $4164.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017543 | 2026-01-12 | Summit Community Hospital | $2,867.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.