CLM-2026-033084
Lakeside Imaging Center, Radiology. Service 2026-07-11 at outpatient hospital (POS 22). Received 2026-09-04.
Member
Resolved through the identity graph
- Member
- Willie Delgado
- Member ID
- UHC-47830-16
- Date of birth
- 1965-09-16
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-422743
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5018
- Coverage period
- 2023-06-01 to present
- Deductible
- $289.39 of $500.0058%
- Out-of-pocket maximum
- $404.73 of $2,000.0020%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4829743648
- Network
- In network
- Rendering NPI
- 4829743648
- Location
- Minneapolis, MN · TIN 87-3632325
- Authorisation / referral
- PA2026798722 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,132.00 | $1,722.60 | — | — | DeniedCO18 |
| Totals | $3,132.00 | $1,722.60 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-645350
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032656 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-11: MEDICARE-ADV-A (MA), effective 2023-06-01. | |
| Timely filing | Pass | Received 55 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-033083: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | Authorisation PA2026798722 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (4829743648). | |
| 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: Lakeside Imaging Center2026-07-11 16:17
Patient seen for unspecified abdominal pain.
- SystemSystem: Claims system2026-09-04 02:43
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Prior auth letterPA2026798722_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-11 to 2026-10-09.
- Itemized billitemized_PA-645350.pdf5 pages
Itemised statement totalling $3132.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-033083: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012136 | 2026-09-17 | Northgate Internal Medicine Associates | $339.00 | Approved |
| CLM-2026-033083 | 2026-07-11 | Lakeside Imaging Center | $3,132.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.