Claims workbench/CLM-2026-001015

Institutional claim · UB-04 · EDI 837I

CLM-2026-001015

Canyon Diagnostic Imaging, Radiology. Service 2026-06-01 at outpatient hospital (POS 22). Received 2026-06-23.

Pended

Billed

$2,544.00

2 lines

Allowed

$1,399.20

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

N30

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Sandra George
Member ID: none on golden record
Date of birth: 1951-06-04
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-413263
Relationship: Self, Sacramento, CA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Canyon Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI: 8055565153
Network: In network
Rendering NPI: 7235030955 (Desert Imaging Center)
Location: Atlanta, GA · TIN 44-7708549
Authorisation / referral: PA2025133689 / 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	77067 rev 0403	Screening mammography, bilateral	—	1	1	$388.00	$213.40	—	—	PendedN30
2	70553 rev 0610	MRI brain with and without contrast	—	1	1	$2,156.00	$1,185.80	—	—	PendedN30
Totals						$2,544.00	$1,399.20	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal

Claim header

Patient account: PA-674570
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-033480 (provisional, link confidence 1.00).
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 22 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-001014, billed by a different provider. Possible duplicate
Prior authorisation	Pass		Authorisation PA2025133689 on file for 70553.
Provider network	Pass		In-network provider Canyon Diagnostic Imaging (8055565153).
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.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Canyon Diagnostic Imaging2026-06-01 15:59
Follow-up for pain in right knee. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-06-23 04:53
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-23 14:28
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2025133689_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-06-01 to 2026-08-30.
Itemized billitemized_PA-674570.pdf7 pages
Itemised statement totalling $2544.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Same member, date of service and procedures as CLM-2026-001014, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-001014	2026-06-01	Desert Imaging Center	$2,544.00	Pended

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

Approvedscenario: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity