Claims workbench/CLM-2026-002869

Institutional claim · UB-04 · EDI 837I

CLM-2026-002869

Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-09-30 at outpatient hospital (POS 22). Received 2026-10-08.

Pended

Billed

$2,983.00

1 line

Allowed

$1,640.65

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

N30

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Camila Munoz
Member ID: none on golden record
Date of birth: 1992-07-04
Identity: Verified2 records, confidence 0.97
Claim record: CLMCLM-400754
Relationship: Self, Tampa, FL

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Northgate Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 6545828207
Network: In network
Rendering NPI: 5576333301
Location: Miami, FL · TIN 98-4961021
Authorisation / referral: PA2026143973 / 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	$2,983.00	$1,640.65	—	—	PendedN30
Totals						$2,983.00	$1,640.65	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. S83.241A Other tear of medial meniscus, right knee, initial encounter
3. M54.50 Low back pain, unspecified

Claim header

Patient account: PA-963319
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-042427 (verified, link confidence 0.97).
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 8 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026143973 on file for 70553.
Provider network	Pass		In-network provider Northgate Orthopedic Specialists (6545828207).
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: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Northgate Orthopedic Specialists2026-09-30 09:02
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Routine screening visit; no acute findings, no red-flag symptoms documented.
SystemSystem: Claims system2026-10-08 06:11
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.

Attachments

Documents received with the claim

Prior auth letterPA2026143973_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-30 to 2026-12-29.
Itemized billitemized_PA-963319.pdf8 pages
Itemised statement totalling $2983.00 across 1 line.
Medical recordrecords_PA-963319.pdf16 pages
Clinic notes for a routine annual visit; no symptoms documented.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Eligibility: No coverage segment found for the member ID on this claim. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.

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

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

DeniedCO50scenario: Dx mismatch

Routine diagnosis does not support advanced imaging.

Review queue Member identity