CLM-2026-033579
Summit Imaging Center, Radiology. Service 2026-05-20 at outpatient hospital (POS 22). Received 2026-06-03.
Member
Resolved through the identity graph
- Member
- Mateo Castro
- Member ID
- UHC-93344-27
- Date of birth
- 1969-09-04
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-406589
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2728
- Coverage period
- 2022-12-01 to present
- Deductible
- $1,527.72 of $3,500.0044%
- Out-of-pocket maximum
- $2,196.94 of $14,000.0016%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 13 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
- none / 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 | $539.00 | $296.45 | $296.45 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $296.00 | $162.80 | $162.80 | $0.00 | Paid |
| Totals | $835.00 | $459.25 | $459.25 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-836037
- 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-015230 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-20: MEDICARE-ADV-A (MA), effective 2022-12-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-05-20 17:11
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-836037.pdf8 pages
Itemised statement totalling $835.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030554 | 2026-09-20 | Unity Clinical Laboratories | $52.00 | Approved |
| CLM-2026-027032 | 2026-04-18 | Harbor Medical Group | $416.00 | Approved |
| CLM-2026-029986 | 2026-02-05 | Sunrise Cardiovascular Associates | $475.00 | 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.