CLM-2026-034597
Sunrise Imaging Center, Radiology. Service 2026-01-23 at outpatient hospital (POS 22). Received 2026-02-26.
Member
Resolved through the identity graph
- Member
- Henry Daniels
- Member ID
- UHC-26249-22
- Date of birth
- 1945-03-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-418599
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8996
- Coverage period
- 2023-10-01 to present
- Deductible
- $165.29 of $1,500.0011%
- Out-of-pocket maximum
- $1,511.18 of $6,000.0025%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 9418627425
- Network
- In network
- Rendering NPI
- 9418627425
- Location
- Mesa, AZ · TIN 78-4773350
- Authorisation / referral
- PA2025700078 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $194.00 | $106.70 | $106.70 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $392.00 | $215.60 | $215.60 | $0.00 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 2 | $3,345.00 | $1,839.75 | $1,260.61 | $579.14 | Paid |
| Totals | $3,931.00 | $2,162.05 | $1,582.91 | $579.14 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-506053
- 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-016105 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-23: CHOICE-PLUS-PPO (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025700078 on file for 70553. | |
| Provider network | Pass | In-network provider Sunrise Imaging Center (9418627425). | |
| 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: Sunrise Imaging Center2026-01-23 16:46
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025700078_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-01-23 to 2026-04-23.
- Itemized billitemized_PA-506053.pdf2 pages
Itemised statement totalling $3931.00 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-2026-031302 | 2026-04-27 | Sunrise Medical Group | $274.00 | 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.