Claims workbench/CLM-2026-006923

Institutional claim · UB-04 · EDI 837I

CLM-2026-006923

Mesa Imaging Center, Radiology. Service 2026-05-10 at outpatient hospital (POS 22). Received 2026-06-03.

PendedReplacement of CLM-2026-006922Out of network

Billed

$3,453.00

3 lines

Allowed

$1,553.85

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

N30

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Janice Kennedy
Member ID: none on golden record
Date of birth: 1948-03-14
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-427991
Relationship: Self, Denver, CO

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Mesa Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 6656135814
Network: Out of network
Rendering NPI: 6656135814
Location: Minneapolis, MN · TIN 75-3868074
Authorisation / referral: PA2026058325 / 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	$2,643.00	$1,189.35	—	—	PendedN30
2	71046 rev 0320	Chest X-ray, two views	—	1	2	$216.00	$97.20	—	—	PendedN30
3	76700 rev 0402	Ultrasound abdomen, complete	—	1	1	$594.00	$267.30	—	—	PendedN30
Totals						$3,453.00	$1,553.85	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal

Claim header

Patient account: PA-419161
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-032014 (provisional, 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 24 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-006922; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		Authorisation PA2026058325 on file for 70553.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Mesa Imaging Center2026-05-10 10:21
Patient seen for pain in right knee. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-06-03 06:04
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-03 12:55
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2026058325_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-05-10 to 2026-08-08.
Itemized billitemized_PA-419161.pdf4 pages
Itemised statement totalling $3453.00 across 3 lines.
Corrected claimcorrected_CLM-2026-006922.pdf1 page
Provider cover letter requesting replacement of CLM-2026-006922.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Eligibility: No coverage segment found for the member ID on this claim. Replacement claim: Frequency code 7 replaces CLM-2026-006922; the original must be voided when this adjudicates. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-006922	2026-05-10	Mesa Imaging Center	$3,453.00	Pended

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

Approvedscenario: Replacement

Replacement claim supersedes the original.

Review queue Member identity