Claims workbench/CLM-2026-009027

Institutional claim · UB-04 · EDI 837I

CLM-2026-009027

Unity Imaging Center, Radiology. Service 2026-09-02 at outpatient hospital (POS 22). Received 2026-10-13.

DeniedOut of network

Billed

$928.00

3 lines

Allowed

$417.60

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Jacob Fields
Member ID: UHC-76092-02
Date of birth: 1996-01-20
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-417564
Relationship: Spouse, Eden Prairie, MN

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-7677
Coverage period: 2021-11-01 to present
Deductible: $259.76 of $500.0052%
Out-of-pocket maximum: $172.06 of $1,000.0017%
Copays: office $30.00, specialist $40.00, emergency $150.00
Physical therapy visits: 9 of 20 used

Provider

Billing and rendering

Billing provider: Unity Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 8566952718
Network: Out of network
Rendering NPI: 8566952718
Location: Miami, FL · TIN 34-7730969
Authorisation / referral: none / REF990417

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	59	1	1	$142.00	$63.90	—	—	DeniedCO204
2	77067 rev 0403	Screening mammography, bilateral	59	1	1	$288.00	$129.60	—	—	DeniedCO204
3	76700 rev 0402	Ultrasound abdomen, complete	25	1	1	$498.00	$224.10	—	—	DeniedCO204
Totals						$928.00	$417.60	—	—

Diagnoses (ICD-10-CM)

1. R07.9 Chest pain, unspecifiedprincipal

Claim header

Patient account: PA-110368
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

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-020952 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-09-02: CORE-HMO (HMO), effective 2021-11-01.
Timely filing	Pass		Received 41 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	Fail	CO204	Billing provider 8566952718 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Unity Imaging Center2026-09-02 12:21
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-10-13 05:36
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-13 15:36
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Itemized billitemized_PA-110368.pdf7 pages
Itemised statement totalling $928.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Provider network: Billing provider 8566952718 is out of network and the HMO plan has no out-of-network benefit. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

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

Denied by Claims rules engine; an examiner may still override

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

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queue Member identity