Claims workbench/CLM-2026-005047

Institutional claim · UB-04 · EDI 837I

CLM-2026-005047

Sunrise Diagnostic Imaging, Radiology. Service 2026-01-05 at outpatient hospital (POS 22). Received 2026-01-31.

Denied

Billed

$3,860.00

2 lines

Allowed

$2,123.00

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Martha Riley
Member ID: UHC-50441-12
Date of birth: 1972-05-20
Identity: Verified3 records, confidence 0.96
Claim record: CLMCLM-431694
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-9965
Coverage period: 2024-04-01 to present
Deductible: $211.04 of $1,500.0014%
Out-of-pocket maximum: $1,001.40 of $4,500.0022%
Copays: office $30.00, specialist $50.00, emergency $350.00
Physical therapy visits: 15 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI: 8125654300
Network: In network
Rendering NPI: 8125654300
Location: Scottsdale, AZ · TIN 88-4094032
Authorisation / referral: PA2026597912 / 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	77067 rev 0403	Screening mammography, bilateral	—	1	1	$260.00	$143.00	—	—	DeniedCO18
2	70553 rev 0610	MRI brain with and without contrast	—	1	2	$3,600.00	$1,980.00	—	—	DeniedCO18
Totals						$3,860.00	$2,123.00	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal

Claim header

Patient account: PA-594147
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-008111 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2026-01-05: OPTIONS-PPO (PPO), effective 2024-04-01.
Timely filing	Pass		Received 26 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-005046: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		Authorisation PA2026597912 on file for 70553.
Provider network	Pass		In-network provider Sunrise Diagnostic Imaging (8125654300).
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: Sunrise Diagnostic Imaging2026-01-05 09:37
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
SystemSystem: Claims system2026-01-31 03:20
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

Attachments

Documents received with the claim

Prior auth letterPA2026597912_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-01-05 to 2026-04-05.
Itemized billitemized_PA-594147.pdf3 pages
Itemised statement totalling $3860.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Duplicate check: Exact duplicate of CLM-2026-005046: same member, date of service, procedures and billing provider. Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-026962	2026-05-26	Mesa Orthopedic Specialists	$206.00	Approved
CLM-2026-005046	2026-01-05	Sunrise Diagnostic Imaging	$3,860.00	Needs review

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