Claims workbench/CLM-2026-006156
Institutional claim · UB-04 · EDI 837I

CLM-2026-006156

Harbor Diabetes Center, Endocrinology. Service 2026-09-26 at outpatient hospital (POS 22). Received 2026-09-30.

Needs review
Billed
$3,358.00
1 line
Allowed
$1,846.90
if approved
Plan pays
—
Needs review
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Review
CO50
Decided by
Nobody yet
open

Member

Resolved through the identity graph

Member
Terry Rojas
Member ID
UHC-95768-18
Date of birth
1939-04-22
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-409999
Relationship
Spouse, Scottsdale, AZ

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-6675
Coverage period
2024-09-01 to present
Deductible
$429.93 of $500.0086%
Out-of-pocket maximum
$105.20 of $2,000.005%
Copays
office $30.00, specialist $60.00, emergency $250.00
Physical therapy visits
21 of 20 used

Provider

Billing and rendering

Billing provider
Harbor Diabetes Center
Endocrinology · taxonomy 207RE0101X
NPI
7519485602
Network
In network
Rendering NPI
9347771872
Location
Tempe, AZ · TIN 55-9687647
Authorisation / referral
PA2025779938 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
170553
rev 0610
MRI brain with and without contrast—11$3,358.00$1,846.90——Review
Totals$3,358.00$1,846.90——
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
Claim header
Patient account
PA-644297
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-037789 (verified, link confidence 1.00).
EligibilityPassActive on 2026-09-26: CHOICE-PLUS-PPO (PPO), effective 2024-09-01.
Timely filingPassReceived 4 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2025779938 on file for 70553.
Provider networkPassIn-network provider Harbor Diabetes Center (7519485602).
Medical necessityReviewCO5070553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Not medically necessary per payer policy
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Harbor Diabetes Center2026-09-26 18:00

    Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Routine screening visit; no acute findings, no red-flag symptoms documented.

  • SystemSystem: Claims system2026-09-30 00:18

    Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.

  • AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-30 11:32

    Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

  • Prior auth letterPA2025779938_approval.pdf2 pages

    Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-26 to 2026-12-25.

  • Itemized billitemized_PA-644297.pdf3 pages

    Itemised statement totalling $3358.00 across 1 line.

  • Medical recordrecords_PA-644297.pdf7 pages

    Clinic notes for a routine annual visit; no symptoms documented.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineReview2026-10-22 12:44
    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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
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 queueMember identity