Claims workbench/CLM-2026-007203

Institutional claim · UB-04 · EDI 837I

CLM-2026-007203

Sunrise Bone and Joint Center, Orthopedic Surgery. Service 2026-06-27 at outpatient hospital (POS 22). Received 2026-07-20.

Needs review

Billed

$2,913.00

1 line

Allowed

$1,602.15

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: Sharon Scott
Member ID: none on golden record
Date of birth: 1977-06-19
Identity: Verified2 records, confidence 1.00
Claim record: CLMCLM-413936
Relationship: Self, San Diego, CA

Coverage and accumulators

Found by name and date of birth

Plan: N/A PPO group GRP-3271
Coverage period: 2023-10-01 to present
Deductible: $314.53 of $500.0063%
Out-of-pocket maximum: $487.93 of $1,500.0033%
Copays: office $40.00, specialist $50.00, emergency $350.00
Physical therapy visits: 0 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 8496214718
Network: In network
Rendering NPI: 1002997132
Location: Nashville, TN · TIN 33-7590536
Authorisation / referral: PA2026988960 / 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	$2,913.00	$1,602.15	—	—	Review
Totals						$2,913.00	$1,602.15	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-106816
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-009330 (verified, link confidence 1.00).
Eligibility	Note		Active on 2026-06-27: N/A (PPO), effective 2023-10-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 23 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026988960 on file for 70553.
Provider network	Pass		In-network provider Sunrise Bone and Joint Center (8496214718).
Medical necessity	Review	CO50	70553 billed with routine diagnosis Z00.00; 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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Bone and Joint Center2026-06-27 13:19
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Routine screening visit; no acute findings, no red-flag symptoms documented.
SystemSystem: Claims system2026-07-20 05:42
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.

Attachments

Documents received with the claim

Prior auth letterPA2026988960_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-27 to 2026-09-25.
Itemized billitemized_PA-106816.pdf2 pages
Itemised statement totalling $2913.00 across 1 line.
Medical recordrecords_PA-106816.pdf11 pages
Clinic notes for a routine annual visit; no symptoms documented.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Eligibility: Active on 2026-06-27: N/A (PPO), effective 2023-10-01. Coverage found by name and date of birth because the claim carried no usable member ID. 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

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

DeniedCO50scenario: Dx mismatch

Routine diagnosis does not support advanced imaging.

Review queue Member identity