Claims workbench/CLM-2026-000853
Institutional claim · UB-04 · EDI 837I

CLM-2026-000853

Summit Diagnostic Imaging, Radiology. Service 2026-04-24 at outpatient hospital (POS 22). Received 2026-05-06.

PendedIdentity on hold: CASE-003937
Billed
$2,995.00
2 lines
Allowed
$1,647.25
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Bryan Gonzalez
Member ID
none on golden record
Date of birth
1963-07-25
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-409639
Relationship
Child, Phoenix, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Summit Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI
8935049519
Network
In network
Rendering NPI
8935049519
Location
Los Angeles, CA · TIN 90-8085018
Authorisation / referral
PA2025995645 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
170553
rev 0610
MRI brain with and without contrast—11$2,746.00$1,510.30——PendedIDQ
277067
rev 0403
Screening mammography, bilateral—11,2$249.00$136.95——PendedIDQ
Totals$2,995.00$1,647.25——
Diagnoses (ICD-10-CM)
  • 1. M25.561 Pain in right kneeprincipal
  • 2. R51.9 Headache, unspecified
Claim header
Patient account
PA-688154
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-003937; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 12 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2025995645 on file for 70553.
Provider networkPassIn-network provider Summit Diagnostic Imaging (8935049519).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Summit Diagnostic Imaging2026-04-24 10:01

    Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

  • Prior auth letterPA2025995645_approval.pdf2 pages

    Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-24 to 2026-07-23.

  • Itemized billitemized_PA-688154.pdf7 pages

    Itemised statement totalling $2995.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-003937; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.

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
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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity