CLM-2026-032043
Sunrise Imaging Center, Radiology. Service 2026-04-16 at outpatient hospital (POS 22). Received 2026-05-31.
Member
Resolved through the identity graph
- Member
- Jack Garza
- Member ID
- UHC-07484-53
- Date of birth
- 1965-12-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415655
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-1125
- Coverage period
- 2023-01-01 to present
- Deductible
- $392.57 of $2,500.0016%
- Out-of-pocket maximum
- $116.09 of $5,000.002%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4303980450
- Network
- In network
- Rendering NPI
- 4303980450
- Location
- Miami, FL · TIN 94-2880728
- Authorisation / referral
- PA2026932617 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,351.00 | $743.05 | $743.05 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | 25 | 1 | 1,2 | $2,023.00 | $1,112.65 | $1,112.65 | $0.00 | Paid |
| Totals | $3,374.00 | $1,855.70 | $1,855.70 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-164694
- 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-021847 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-16: UNKNOWN (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026932617 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Sunrise Imaging Center (4303980450). | |
| 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 Center2026-04-16 16:05
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026932617_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-04-16 to 2026-07-15.
- Itemized billitemized_PA-164694.pdf7 pages
Itemised statement totalling $3374.00 across 2 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-2026-009189 | 2026-08-09 | Valley Clinical Laboratories | $105.00 | Approved |
| CLM-2026-008418 | 2026-05-20 | Valley Rehabilitation Center | $201.00 | Denied |
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.