Institutional claim · UB-04 · Paper
CLM-2026-007978
Northgate Imaging Center, Radiology. Service 2026-03-18 at outpatient hospital (POS 22). Received 2026-03-29.
Billed
$750.00
2 lines
Allowed
$337.50
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Jessica Dean
- Member ID
- none on golden record
- Date of birth
- 1966-03-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-424064
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- NULL PPO group GRP-2244
- Coverage period
- 2022-04-01 to present
- Deductible
- $2,088.20 of $3,500.0060%
- Out-of-pocket maximum
- $1,564.15 of $7,000.0022%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3050464585
- Network
- Out of network
- Rendering NPI
- 3050464585
- Location
- San Diego, CA · TIN 61-2250278
- Authorisation / referral
- none / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $223.00 | $100.35 | — | — | PendedIDQ |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $527.00 | $237.15 | — | — | PendedIDQ |
| Totals | $750.00 | $337.50 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
Claim header
- Patient account
- PA-355491
- 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 | Fail | IDQ | Member record is in open steward case CASE-002739; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-03-18: NULL (PPO), effective 2022-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Imaging Center2026-03-18 13:30
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Itemized billitemized_PA-355491.pdf3 pages
Itemised statement totalling $750.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002739; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-18: NULL (PPO), effective 2022-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. 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-2026-007979 | 2026-03-18 | Northgate Imaging Center | $750.00 | 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
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.