Claims workbench/CLM-2026-004255

Institutional claim · UB-04 · EDI 837I

CLM-2026-004255

Pinecrest Diagnostic Imaging, Radiology. Service 2026-01-09 at outpatient hospital (POS 22). Received 2026-01-20.

DeniedIdentity on hold: CASE-001228

Billed

$3,517.00

2 lines

Allowed

$1,934.35

if approved

Plan pays

—

Denied

Member owes

—

no coverage

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Juddy Schultz
Member ID: none on golden record
Date of birth: 1971-11-05
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-401641
Relationship: Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Pinecrest Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI: 8391485629
Network: In network
Rendering NPI: 8391485629
Location: Scottsdale, AZ · TIN 15-2373170
Authorisation / referral: PA2025536669 / 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	$3,221.00	$1,771.55	—	—	DeniedCO18
2	77067 rev 0403	Screening mammography, bilateral	—	1	1	$296.00	$162.80	—	—	DeniedCO18
Totals						$3,517.00	$1,934.35	—	—

Diagnoses (ICD-10-CM)

1. R07.9 Chest pain, unspecifiedprincipal

Claim header

Patient account: PA-481644
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	IDQ	Member record is in open steward case CASE-001228; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 11 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-004254: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		Authorisation PA2025536669 on file for 70553.
Provider network	Pass		In-network provider Pinecrest Diagnostic Imaging (8391485629).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Diagnostic Imaging2026-01-09 17:30
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-01-20 01:44
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-20 16:56
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2025536669_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-09 to 2026-04-09.
Itemized billitemized_PA-481644.pdf4 pages
Itemised statement totalling $3517.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Member identity: Member record is in open steward case CASE-001228; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Exact duplicate of CLM-2026-004254: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-004254	2026-01-09	Pinecrest Diagnostic Imaging	$3,517.00	Pended

AI recommendation

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

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

Examiner decision

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity