CLM-2026-033086
Lakeside Imaging Center, Radiology. Service 2026-03-22 at outpatient hospital (POS 22). Received 2026-05-01.
Member
Resolved through the identity graph
- Member
- Laura Alvarez
- Member ID
- UHC-59481-37
- Date of birth
- 1994-01-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-404830
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4260
- Coverage period
- 2025-06-01 to present
- Deductible
- $265.58 of $500.0053%
- Out-of-pocket maximum
- $294.49 of $1,000.0029%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3836779710
- Network
- In network
- Rendering NPI
- 3836779710
- Location
- Nashville, TN · TIN 29-1460766
- Authorisation / referral
- PA2025261064 / 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 | $390.00 | $214.50 | $214.50 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,625.00 | $893.75 | $282.07 | $611.68 | Paid |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $169.00 | $92.95 | $27.89 | $65.06 | Paid |
| Totals | $2,184.00 | $1,201.20 | $524.46 | $676.74 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-332900
- 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-028678 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-22: SELECT-EPO (EPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025261064 on file for 74177. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (3836779710). | |
| 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 Center2026-03-22 13:30
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025261064_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-03-22 to 2026-06-20.
- Itemized billitemized_PA-332900.pdf2 pages
Itemised statement totalling $2184.00 across 3 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-2026-030740 | 2026-04-29 | Harbor Medical Group | $17.00 | Approved |
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.