CLM-2026-032360
Heritage Imaging Center, Radiology. Service 2026-09-29 at outpatient hospital (POS 22). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Arthur Hall
- Member ID
- UHC-60721-03
- Date of birth
- 2003-11-19
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-430447
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6962
- Coverage period
- 2022-10-01 to present
- Deductible
- $1,156.13 of $1,500.0077%
- Out-of-pocket maximum
- $1,993.89 of $4,500.0044%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4466693437
- Network
- In network
- Rendering NPI
- 4466693437
- Location
- Atlanta, GA · TIN 36-7680074
- 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 | $480.00 | $264.00 | $264.00 | $0.00 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $177.00 | $97.35 | $83.37 | $13.98 | Paid |
| Totals | $657.00 | $361.35 | $347.37 | $13.98 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-116077
- 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-032934 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-29: CHOICE-PLUS-PPO (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Heritage Imaging Center (4466693437). | |
| 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: Heritage Imaging Center2026-09-29 12:09
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-116077.pdf9 pages
Itemised statement totalling $657.00 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
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.