Claims workbench/CLM-2026-010427

Institutional claim · UB-04 · EDI 837I

CLM-2026-010427

Sunrise Imaging Center, Radiology. Service 2026-08-03 at outpatient hospital (POS 22). Received 2026-08-16.

Denied

Billed

$1,893.00

3 lines

Allowed

$1,041.15

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Nathan Cole
Member ID: UHC-77282-78
Date of birth: 1958-07-27
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-417879
Relationship: Self, Austin, TX

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-4125
Coverage period: 2024-05-01 to present
Deductible: $158.10 of $1,000.0016%
Out-of-pocket maximum: $598.89 of $2,000.0030%
Copays: office $25.00, specialist $60.00, emergency $150.00
Physical therapy visits: 9 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 4303980450
Network: In network
Rendering NPI: 4303980450
Location: Miami, FL · TIN 94-2880728
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	$215.00	$118.25	—	—	DeniedCO197
2	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	2	$1,448.00	$796.40	—	—	DeniedCO197
3	77067 rev 0403	Screening mammography, bilateral	—	1	2	$230.00	$126.50	—	—	DeniedCO197
Totals						$1,893.00	$1,041.15	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
2. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-884969
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-015651 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-03: MEDICARE-ADV-B (MA), effective 2024-05-01.
Timely filing	Pass		Received 13 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	74177 require precertification; no authorisation number on the claim. Precertification or authorization absent
Provider network	Pass		In-network provider Sunrise Imaging Center (4303980450).
Medical necessity	Review	CO50	74177 billed with routine diagnosis Z12.31; 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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Imaging Center2026-08-03 10:30
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-08-16 05:29
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.

Attachments

Documents received with the claim

Itemized billitemized_PA-884969.pdf3 pages
Itemised statement totalling $1893.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Prior authorisation: 74177 require precertification; no authorisation number on the claim. Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-033099	2026-09-12	Cornerstone Internal Medicine Associates	$390.00	Approved
CLM-2026-034021	2026-01-22	Unity Cardiovascular Associates	$8,674.00	Approved

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

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity