Claims workbench/CLM-2026-004614

Institutional claim · UB-04 · Paper

CLM-2026-004614

Desert Diagnostic Imaging, Radiology. Service 2025-12-16 at outpatient hospital (POS 22). Received 2026-01-23.

DeniedIdentity on hold: CASE-001817

Billed

$2,858.00

2 lines

Allowed

$1,571.90

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Eric Rios
Member ID: none on golden record
Date of birth: 1966-11-03
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-411210
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: MEDICARE-ADV-B MA group GRP-2724
Coverage period: 2021-05-01 to present
Deductible: $599.84 of $3,500.0017%
Out-of-pocket maximum: $3,035.83 of $7,000.0043%
Copays: office $25.00, specialist $40.00, emergency $250.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Desert Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI: 2571625872
Network: In network
Rendering NPI: 2571625872
Location: Dallas, TX · TIN 43-0454627
Authorisation / referral: none / 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	$2,747.00	$1,510.85	—	—	DeniedCO197
2	71046 rev 0320	Chest X-ray, two views	—	1	1	$111.00	$61.05	—	—	DeniedCO197
Totals						$2,858.00	$1,571.90	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
2. R51.9 Headache, unspecified

Claim header

Patient account: PA-825664
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 4 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-001817; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2025-12-16: MEDICARE-ADV-B (MA), effective 2021-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 38 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	70553 require precertification; no authorisation number on the claim. Precertification or authorization absent
Provider network	Pass		In-network provider Desert Diagnostic Imaging (2571625872).
Medical necessity	Review	CO50	70553 billed with routine diagnosis Z12.31; 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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Desert Diagnostic Imaging2025-12-16 15:28
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
SystemSystem: Claims system2026-01-23 01:22
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.

Attachments

Documents received with the claim

Itemized billitemized_PA-825664.pdf5 pages
Itemised statement totalling $2858.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Member identity: Member record is in open steward case CASE-001817; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-16: MEDICARE-ADV-B (MA), effective 2021-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. Prior authorisation: 70553 require precertification; no authorisation number on the claim. Medical necessity: 70553 billed with routine diagnosis Z12.31; 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

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

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity