CLM-2026-031515
Riverside Imaging Center, Radiology. Service 2026-06-13 at outpatient hospital (POS 22). Received 2026-07-26.
Member
Resolved through the identity graph
- Member
- Teresa McCoy
- Member ID
- UHC-16722-55
- Date of birth
- 1976-08-20
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-402581
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0527
- Coverage period
- 2023-09-01 to present
- Deductible
- $149.40 of $500.0030%
- Out-of-pocket maximum
- $358.19 of $1,000.0036%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7550181540
- Network
- In network
- Rendering NPI
- 4466693437 (Heritage Imaging Center)
- Location
- Charlotte, NC · TIN 65-3901057
- 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 | $144.00 | $79.20 | — | — | Review |
| Totals | $144.00 | $79.20 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-222417
- 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-033009 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-13: CHOICE-PLUS-PPO (PPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-031514, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Imaging Center (7550181540). | |
| 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 Center2026-06-13 15:28
Patient seen for unspecified abdominal pain. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-07-26 02:43
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-26 14:56
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-222417.pdf9 pages
Itemised statement totalling $144.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-031514, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031514 | 2026-06-13 | Heritage Imaging Center | $144.00 | Approved |
| CLM-2026-017514 | 2026-05-20 | Summit Regional Medical Center | $3,831.00 | Approved |
| CLM-2026-029042 | 2026-05-18 | Meadow Medical Group | $245.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.