Claims workbench/CLM-2026-002153

Institutional claim · UB-04 · EDI 837I

CLM-2026-002153

Sunrise Imaging Center, Radiology. Service 2026-07-03 at outpatient hospital (POS 22). Received 2026-07-05.

DeniedOut of network

Billed

$2,368.00

2 lines

Allowed

$1,065.60

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Mary Miller
Member ID: UHC-95565-83
Date of birth: 1940-11-17
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-418923
Relationship: Self, Minneapolis, MN

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-4373
Coverage period: 2024-11-01 to present
Deductible: $1,339.08 of $2,500.0054%
Out-of-pocket maximum: $336.47 of $10,000.003%
Copays: office $40.00, specialist $50.00, emergency $350.00
Physical therapy visits: 16 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 9630195771
Network: Out of network
Rendering NPI: 9630195771
Location: Dallas, TX · TIN 60-5457120
Authorisation / referral: PA2026102504 / REF887981

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	59	1	1	$1,905.00	$857.25	—	—	DeniedCO204
2	76700 rev 0402	Ultrasound abdomen, complete	59	1	1	$463.00	$208.35	—	—	DeniedCO204
Totals						$2,368.00	$1,065.60	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal
2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast

Claim header

Patient account: PA-470677
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-002362 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-07-03: NAVIGATE-HMO (HMO), effective 2024-11-01.
Timely filing	Pass		Received 2 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026102504 on file for 70553.
Provider network	Fail	CO204	Billing provider 9630195771 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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: Sunrise Imaging Center2026-07-03 13:39
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-07-05 03:15
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.

Attachments

Documents received with the claim

Prior auth letterPA2026102504_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-03 to 2026-10-01.
Itemized billitemized_PA-470677.pdf7 pages
Itemised statement totalling $2368.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Provider network: Billing provider 9630195771 is out of network and the HMO plan has no out-of-network benefit. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-024292	2026-04-29	Mesa Internal Medicine Associates	$279.00	Denied

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

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queue Member identity