Claims workbench/CLM-2026-000553

Institutional claim · UB-04 · EDI 837I

CLM-2026-000553

Desert Imaging Center, Radiology. Service 2026-08-30 at outpatient hospital (POS 22). Received 2026-09-04.

PendedIdentity on hold: CASE-004093

Billed

$132.00

1 line

Allowed

$72.60

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Austin Lopez
Member ID: none on golden record
Date of birth: 1962-12-26
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-408696
Relationship: Self, San Antonio, TX

Coverage and accumulators

Found by name and date of birth

Plan: NAVIGATE-HMO HMO group GRP-4878
Coverage period: 2023-10-01 to present
Deductible: $1,253.80 of $2,500.0050%
Out-of-pocket maximum: $105.82 of $5,000.002%
Copays: office $40.00, specialist $60.00, emergency $150.00
Physical therapy visits: 15 of 20 used

Provider

Billing and rendering

Billing provider: Desert Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 3553360983
Network: In network
Rendering NPI: 3553360983
Location: Atlanta, GA · TIN 73-9549264
Authorisation / referral: none / REF363007

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	$132.00	$72.60	—	—	PendedIDQ
Totals						$132.00	$72.60	—	—

Diagnoses (ICD-10-CM)

1. R51.9 Headache, unspecifiedprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-992700
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-004093; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-08-30: NAVIGATE-HMO (HMO), effective 2023-10-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 5 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 Desert Imaging Center (3553360983).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Established patient presents with headache, unspecified; symptoms reviewed and vitals with”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Desert Imaging Center2026-08-30 09:23
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
SystemSystem: Claims system2026-09-04 04:29
Rendering provider signature missing on the attached note. Development letter sent to provider.

Attachments

Documents received with the claim

Itemized billitemized_PA-992700.pdf4 pages
Itemised statement totalling $132.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-004093; payment withheld until the identity is confirmed. Eligibility: Active on 2026-08-30: NAVIGATE-HMO (HMO), effective 2023-10-01. Coverage found by name and date of birth because the claim carried no usable member ID. Completeness: Documentation incomplete: “Established patient presents with headache, unspecified; symptoms reviewed and vitals with”.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity