CLM-2026-033496
Lakeside Imaging Center, Radiology. Service 2026-03-04 at outpatient hospital (POS 22). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Priya Santos
- Member ID
- UHC-17238-16
- Date of birth
- 1994-05-09
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-431408
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8156
- Coverage period
- 2024-01-01 to present
- Deductible
- $2,773.53 of $3,500.0079%
- Out-of-pocket maximum
- $3,371.56 of $10,500.0032%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 2856185642
- Network
- In network
- Rendering NPI
- 2856185642
- Location
- Miami, FL · TIN 71-0753822
- Authorisation / referral
- PA2025747390 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,654.00 | $909.70 | $744.79 | $164.91 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $366.00 | $201.30 | $20.13 | $181.17 | Paid |
| Totals | $2,020.00 | $1,111.00 | $764.92 | $346.08 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-298047
- 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-005816 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-04: OPTIONS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025747390 on file for 74177. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (2856185642). | |
| 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 Center2026-03-04 18:17
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025747390_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-03-04 to 2026-06-02.
- Itemized billitemized_PA-298047.pdf2 pages
Itemised statement totalling $2020.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028207 | 2026-02-18 | Evergreen Family Practice | $545.00 | Approved |
| CLM-2026-016355 | 2026-01-17 | Desert Regional Medical Center | $4,150.00 | Needs review |
| CLM-2026-016354 | 2026-01-17 | Desert Regional Medical Center | $4,150.00 | Approved |
| CLM-2026-012868 | 2025-12-12 | Meadow Primary Care Associates | $306.00 | 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.