CLM-2026-000866
Riverside Imaging Center, Radiology. Service 2026-07-25 at outpatient hospital (POS 22). Received 2026-08-09.
Member
Resolved through the identity graph
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Riverside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 7427092680
- Network
- In network
- Rendering NPI
- 7427092680
- Location
- Mesa, AZ · TIN 33-8428995
- 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 | $611.00 | $336.05 | — | — | PendedCO16 |
| Totals | $611.00 | $336.05 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R51.9 Headache, unspecified
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-220005
- 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 | CO16 | Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 15 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 Riverside Imaging Center (7427092680). | |
| 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 pain in right knee; symptoms reviewed and vitals within ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Imaging Center2026-07-25 18:21
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-08-09 04:25
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-09 15:26
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-220005.pdf7 pages
Itemised statement totalling $611.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Claim record is not attached to a resolved identity. Eligibility: No coverage segment found for the member ID on this claim. Completeness: Documentation incomplete: “Established patient presents with pain in right knee; symptoms reviewed and vitals within ”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.