Claims workbench/CLM-2026-001695

Institutional claim · UB-04 · EDI 837I

CLM-2026-001695

Valley Heart Institute, Cardiology. Service 2026-06-23 at outpatient hospital (POS 22). Received 2026-07-11.

Denied

Billed

$2,457.00

2 lines

Allowed

$1,351.35

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Michael Boyd
Member ID: UHC-19257-78
Date of birth: 1992-07-23
Identity: Verified5 records, confidence 0.94
Claim record: CLMCLM-402075
Relationship: Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-7333
Coverage period: 2022-09-01 to 2026-02-28
Deductible: $410.38 of $1,500.0027%
Out-of-pocket maximum: $808.30 of $6,000.0013%
Copays: office $25.00, specialist $60.00, emergency $250.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Valley Heart Institute
Cardiology · taxonomy 207RC0000X
NPI: 1412691184
Network: In network
Rendering NPI: 8444102759
Location: Atlanta, GA · TIN 70-2461607
Authorisation / referral: PA2025320862 / 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	70553 rev 0610	MRI brain with and without contrast	—	1	1	$2,002.00	$1,101.10	—	—	DeniedCO27
2	93015	Cardiovascular stress test	—	1	1	$455.00	$250.25	—	—	DeniedCO27
Totals						$2,457.00	$1,351.35	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. I48.91 Unspecified atrial fibrillation

Claim header

Patient account: PA-984287
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

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-004313 (verified, link confidence 0.94).
Eligibility	Fail	CO27	Date of service 2026-06-23 is after coverage terminated on 2026-02-28. Expenses incurred after coverage terminated
Timely filing	Pass		Received 18 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025320862 on file for 70553.
Provider network	Pass		In-network provider Valley Heart Institute (1412691184).
Medical necessity	Review	CO50	70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Heart Institute2026-06-23 11:15
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-07-11 04:42
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-11 16:09
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2025320862_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-23 to 2026-09-21.
Itemized billitemized_PA-984287.pdf9 pages
Itemised statement totalling $2457.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-06-23 is after coverage terminated on 2026-02-28. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-032630	2025-12-01	Meadow Reference Lab	$140.00	Denied
CLM-2026-032629	2025-12-01	Meadow Reference Lab	$140.00	Approved

AI recommendation

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

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

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity