Claims workbench/CLM-2026-006067

Institutional claim · UB-04 · EDI 837I

CLM-2026-006067

Harbor Imaging Center, Radiology. Service 2026-01-10 at outpatient hospital (POS 22). Received 2026-01-27.

Pended

Billed

$3,628.00

2 lines

Allowed

$1,995.40

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

N30

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Cheryl Carroll
Member ID: none on golden record
Date of birth: 1988-05-10
Identity: Verified2 records, confidence 1.00
Claim record: CLMCLM-430337
Relationship: Self, Phoenix, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Harbor Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 3423421452
Network: In network
Rendering NPI: 3423421452
Location: Denver, CO · TIN 47-9293451
Authorisation / referral: PA2025811385 / 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	76700 rev 0402	Ultrasound abdomen, complete	59	1	1	$638.00	$350.90	—	—	PendedN30
2	70553 rev 0610	MRI brain with and without contrast	59	1	2	$2,990.00	$1,644.50	—	—	PendedN30
Totals						$3,628.00	$1,995.40	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-637379
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-008068 (verified, link confidence 1.00).
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 17 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025811385 on file for 70553.
Provider network	Pass		In-network provider Harbor Imaging Center (3423421452).
Medical necessity	Review	CO50	70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Harbor Imaging Center2026-01-10 13:59
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-01-27 04:40
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.

Attachments

Documents received with the claim

Prior auth letterPA2025811385_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-01-10 to 2026-04-10.
Itemized billitemized_PA-637379.pdf9 pages
Itemised statement totalling $3628.00 across 2 lines.
Medical recordrecords_PA-637379.pdf6 pages
Operative note describes a single procedure at one site; no separate session.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Eligibility: No coverage segment found for the member ID on this claim. Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. 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

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

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity