CLM-2026-033464
Summit Imaging Center, Radiology. Service 2026-02-21 at outpatient hospital (POS 22). Received 2026-03-25.
Member
Resolved through the identity graph
- Member
- Priya Cook
- Member ID
- UHC-96152-36
- Date of birth
- 1956-08-04
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-406887
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2513
- Coverage period
- 2023-01-01 to present
- Deductible
- $284.65 of $1,000.0028%
- Out-of-pocket maximum
- $283.85 of $2,000.0014%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4562878908
- Network
- In network
- Rendering NPI
- 4562878908
- Location
- Minneapolis, MN · TIN 57-8653616
- Authorisation / referral
- PA2025490342 / 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 | $1,886.00 | $1,037.30 | $811.94 | $225.36 | Paid |
| Totals | $1,886.00 | $1,037.30 | $811.94 | $225.36 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-281562
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006563 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-21: MEDICARE-ADV-B (MA), effective 2023-01-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025490342 on file for 70553. | |
| Provider network | Pass | In-network provider Summit Imaging Center (4562878908). | |
| 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: Summit Imaging Center2026-02-21 10:36
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025490342_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-02-21 to 2026-05-22.
- Itemized billitemized_PA-281562.pdf8 pages
Itemised statement totalling $1886.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008105 | 2026-06-14 | Harbor Family Practice | $164.00 | Approved |
| CLM-2026-006996 | 2026-07-08 | Unity Primary Care Associates | $298.00 | Approved |
| CLM-2026-027958 | 2026-04-29 | Meadow Regional Medical Center | $3,450.00 | Approved |
| CLM-2026-033465 | 2026-02-21 | Summit Imaging Center | $1,886.00 | 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.