CLM-2026-032894
Riverside Imaging Center, Radiology. Service 2026-06-19 at outpatient hospital (POS 22). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Nicholas Arnold
- Member ID
- UHC-28133-87
- Date of birth
- 1980-06-27
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-425056
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1906
- Coverage period
- 2021-05-01 to present
- Deductible
- $571.19 of $2,500.0023%
- Out-of-pocket maximum
- $1,368.85 of $7,500.0018%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7550181540
- Network
- In network
- Rendering NPI
- 7550181540
- Location
- Charlotte, NC · TIN 65-3901057
- Authorisation / referral
- PA2025152986 / 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 | $166.00 | $91.30 | $91.30 | $0.00 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $1,879.00 | $1,033.45 | $1,033.45 | $0.00 | Paid |
| Totals | $2,045.00 | $1,124.75 | $1,124.75 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-934566
- 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-020836 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-19: MEDICARE-ADV-A (MA), effective 2021-05-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025152986 on file for 70553. | |
| 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 Center2026-06-19 10:49
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2025152986_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-06-19 to 2026-09-17.
- Itemized billitemized_PA-934566.pdf5 pages
Itemised statement totalling $2045.00 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.