CLM-2026-033860
Lakeside Imaging Center, Radiology. Service 2026-07-03 at outpatient hospital (POS 22). Received 2026-07-29.
Member
Resolved through the identity graph
- Member
- Ralph Sullivan
- Member ID
- UHC-55195-82
- Date of birth
- 1944-12-18
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-416764
- Relationship
- Child, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9150
- Coverage period
- 2021-09-01 to present
- Deductible
- $1,313.37 of $1,500.0088%
- Out-of-pocket maximum
- $2,563.11 of $6,000.0043%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 18 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
- 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,201.00 | $660.55 | — | — | DeniedCO197 |
| Totals | $1,201.00 | $660.55 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R51.9 Headache, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-267889
- 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-020367 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-03: OPTIONS-PPO (PPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2026-07-03 17:51
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-29 01:49
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-29 11:21
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-267889.pdf3 pages
Itemised statement totalling $1201.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 74177 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016312 | 2026-08-19 | Pinecrest Diagnostic Imaging | $2,285.00 | Needs review |
| CLM-2026-026104 | 2026-02-01 | Cornerstone Orthopedic Specialists | $2,047.00 | Needs review |
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
Precertification required and absent.