Claims workbench/CLM-2026-010826

Institutional claim · UB-04 · EDI 837I

CLM-2026-010826

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

Needs review

Billed

$2,389.00

2 lines

Allowed

$1,313.95

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

CO50, CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Evelyn Wilson
Member ID: UHC-19839-19
Date of birth: 1962-02-16
Identity: Verified4 records, confidence 0.97
Claim record: CLMCLM-404627
Relationship: Self, Plano, TX

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-3850
Coverage period: 2022-08-01 to present
Deductible: $637.01 of $1,500.0042%
Out-of-pocket maximum: $198.58 of $6,000.003%
Copays: office $40.00, specialist $50.00, emergency $150.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Valley Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 5964910181
Network: In network
Rendering NPI: 5964910181
Location: Austin, TX · TIN 60-0192260
Authorisation / referral: PA2026492004 / REF828290

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	$2,212.00	$1,216.60	—	—	Review
2	71046 rev 0320	Chest X-ray, two views	25	1	1	$177.00	$97.35	—	—	Review
Totals						$2,389.00	$1,313.95	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
2. R51.9 Headache, unspecified
3. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-605150
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-022146 (verified, link confidence 0.97).
Eligibility	Pass		Active on 2026-09-02: CORE-HMO (HMO), effective 2022-08-01.
Timely filing	Pass		Received 38 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026492004 on file for 70553.
Provider network	Pass		In-network provider Valley Imaging Center (5964910181).
Medical necessity	Review	CO50	70553 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	Review	CO16	Documentation incomplete: “Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Note ”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Imaging Center2026-09-02 17:14
Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Note dictated; signature pending.
SystemSystem: Claims system2026-10-10 05:26
Rendering provider signature missing on the attached note. Development letter sent to provider.

Attachments

Documents received with the claim

Prior auth letterPA2026492004_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-02 to 2026-12-01.
Itemized billitemized_PA-605150.pdf9 pages
Itemised statement totalling $2389.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Completeness: Documentation incomplete: “Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Note ”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-025215	2026-05-27	Meadow Imaging Center	$2,011.00	Needs review
CLM-2026-005696	2026-05-28	Cornerstone Family Practice	$495.00	Denied

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity