Claims workbench/CLM-2026-006747
Institutional claim · UB-04 · Paper

CLM-2026-006747

Meadow Imaging Center, Radiology. Service 2026-01-02 at outpatient hospital (POS 22). Received 2026-01-31.

PendedIdentity on hold: CASE-002192
Billed
$2,621.00
2 lines
Allowed
$1,441.55
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Sara Burton
Member ID
none on golden record
Date of birth
1941-10-24
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-416969
Relationship
Self, Gilbert, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Meadow Imaging Center
Radiology · taxonomy 2085R0202X
NPI
1741122406
Network
In network
Rendering NPI
1741122406
Location
Minneapolis, MN · TIN 23-3617085
Authorisation / referral
PA2026857119 / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
174177
rev 0350
CT abdomen and pelvis with contrast—11$2,387.00$1,312.85——PendedIDQ
277067
rev 0403
Screening mammography, bilateral—12$234.00$128.70——PendedIDQ
Totals$2,621.00$1,441.55——
Diagnoses (ICD-10-CM)
  • 1. R07.9 Chest pain, unspecifiedprincipal
  • 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
Claim header
Patient account
PA-858840
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-002192; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 29 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026857119 on file for 74177.
Provider networkPassIn-network provider Meadow Imaging Center (1741122406).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Meadow Imaging Center2026-01-02 13:04

    Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Prior auth letterPA2026857119_approval.pdf2 pages

    Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-01-02 to 2026-04-02.

  • Itemized billitemized_PA-858840.pdf4 pages

    Itemised statement totalling $2621.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-002192; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.

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
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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity