Claims workbench/CLM-2026-010207

Institutional claim · UB-04 · EDI 837I

CLM-2026-010207

Lakeside Imaging Center, Radiology. Service 2026-01-10 at outpatient hospital (POS 22). Received 2026-01-20.

Needs review

Billed

$3,766.00

2 lines

Allowed

$2,071.30

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO50

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Bruce Gilbert
Member ID: UHC-15741-39
Date of birth: 1999-12-14
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-412439
Relationship: Self, Charlotte, NC

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-4967
Coverage period: 2023-10-01 to present
Deductible: $1,767.53 of $3,500.0051%
Out-of-pocket maximum: $1,544.64 of $7,000.0022%
Copays: office $25.00, specialist $60.00, emergency $250.00
Physical therapy visits: 10 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 2856185642
Network: In network
Rendering NPI: 2856185642
Location: Miami, FL · TIN 71-0753822
Authorisation / referral: PA2025231701 / 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	$3,571.00	$1,964.05	—	—	Review
2	71046 rev 0320	Chest X-ray, two views	25	1	2	$195.00	$107.25	—	—	Review
Totals						$3,766.00	$2,071.30	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-851593
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-006208 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-01-10: SELECT-EPO (EPO), effective 2023-10-01.
Timely filing	Pass		Received 10 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025231701 on file for 70553.
Provider network	Pass		In-network provider Lakeside Imaging Center (2856185642).
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: Lakeside Imaging Center2026-01-10 18:00
Patient seen for encounter for general adult medical examination without abnormal findings. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
SystemSystem: Claims system2026-01-20 06:19
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 letterPA2025231701_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-10 to 2026-04-10.
Itemized billitemized_PA-851593.pdf8 pages
Itemised statement totalling $3766.00 across 2 lines.
Medical recordrecords_PA-851593.pdf6 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
AI recommendationApproved2026-10-23 19:19
The claim for an MRI brain with and without contrast (70553) and a chest X-ray (71046) is supported by the clinical note [N1] which documents progressive neurological symptoms and failed conservative therapy over 8 weeks, justifying the medical necessity of the MRI. The prior authorisation [A1] is valid and matches the service provided. The provider is in-network [PRV], and the member is eligible [IDN][COV]. The claim is within the auto-adjudication ceiling and does not exceed benefit limits [R-high_dollar][R-benefit_limit]. All required documentation is present [R-completeness], and there are no bundling conflicts [R-ncci]. The timely filing requirement is met [R-timely_filing], and there are no duplicate claims [R-duplicate]. The chest X-ray is billed with a routine diagnosis, but it is not the focus of the clinical edit flag, which is on the MRI. The MRI is supported by the clinical note and prior authorisation, so the claim is approvable.
AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:19 · 4beadf94

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode

Approvedconfidence 0.95 Validated

The claim for an MRI brain with and without contrast (70553) and a chest X-ray (71046) is supported by the clinical note [N1] which documents progressive neurological symptoms and failed conservative therapy over 8 weeks, justifying the medical necessity of the MRI. The prior authorisation [A1] is valid and matches the service provided. The provider is in-network [PRV], and the member is eligible [IDN][COV]. The claim is within the auto-adjudication ceiling and does not exceed benefit limits [R-high_dollar][R-benefit_limit]. All required documentation is present [R-completeness], and there are no bundling conflicts [R-ncci]. The timely filing requirement is met [R-timely_filing], and there are no duplicate claims [R-duplicate]. The chest X-ray is billed with a routine diagnosis, but it is not the focus of the clinical edit flag, which is on the MRI. The MRI is supported by the clinical note and prior authorisation, so the claim is approvable.

Evidence cited: [C][DX][L1][L2][PRV][IDN][COV][R-identity][R-eligibility][R-timely_filing][R-duplicate][R-prior_auth][R-network][R-clinical_edit][R-ncci][R-benefit_limit][R-completeness][R-high_dollar][N1][N2][A1][A2][A3]

Latency

3,464 ms

Tokens

1,463 in / 396 out

Cost

$0.0024

Input hash 05ca00842c1a75d9… · identifiers withheld from the model: name, dob, member_id

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Pre-filled from the AI recommendation. Change anything before you record 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 *

Agree with AI recommendation (confidence 0.95): The claim for an MRI brain with and without contrast (70553) and a chest X-ray (71046) is supported by the clinical note [N1] which documents progressive neurological symptoms and failed conservative therapy over 8 weeks, justifying the medical necessity of the MRI. The prior authorisation [A1] is valid and matches the service provided. The provider is in-network [PRV], and the member is eligible [IDN][COV]. The claim is within the auto-adjudication ceiling and does not exceed benefit limits [R-high_dollar][R-benefit_limit]. All required documentation is present [R-completeness], and there are no bundling conflicts [R-ncci]. The timely filing requirement is met [R-timely_filing], and there are no duplicate claims [R-duplicate]. The chest X-ray is billed with a routine diagnosis, but it is not the focus of the clinical edit flag, which is on the MRI. The MRI is supported by the clinical note and prior authorisation, so the claim is approvable.

1004 characters

ExaminerR. Patel (Claims Examiner II)

Will apply: approve

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Dx mismatch

Notes document medical necessity.

Review queue Member identity