Claims workbench/CLM-2026-011702

Institutional claim · UB-04 · EDI 837I

CLM-2026-011702

Evergreen Medical Group, Family Medicine. Service 2026-06-20 at outpatient hospital (POS 22). Received 2026-07-06.

Denied

Billed

$3,191.00

1 line

Allowed

$1,755.05

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Randy Flores
Member ID: UHC-96097-03
Date of birth: 1949-04-14
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-419055
Relationship: Self, Orlando, FL

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-8784
Coverage period: 2025-09-01 to 2026-05-10
Deductible: $2,908.37 of $3,500.0083%
Out-of-pocket maximum: $6,887.23 of $14,000.0049%
Copays: office $25.00, specialist $40.00, emergency $250.00
Physical therapy visits: 9 of 20 used

Provider

Billing and rendering

Billing provider: Evergreen Medical Group
Family Medicine · taxonomy 207Q00000X
NPI: 2175082280
Network: In network
Rendering NPI: 7692214530
Location: Scottsdale, AZ · TIN 79-9933181
Authorisation / referral: PA2025806755 / 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	$3,191.00	$1,755.05	—	—	DeniedCO27
Totals						$3,191.00	$1,755.05	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal

Claim header

Patient account: PA-392519
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-005234 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-06-20 is after coverage terminated on 2026-05-10. Expenses incurred after coverage terminated
Timely filing	Pass		Received 16 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025806755 on file for 70553.
Provider network	Pass		In-network provider Evergreen Medical Group (2175082280).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Evergreen Medical Group2026-06-20 17:18
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-07-06 02:34

Attachments

Documents received with the claim

Prior auth letterPA2025806755_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-20 to 2026-09-18.
Itemized billitemized_PA-392519.pdf5 pages
Itemised statement totalling $3191.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-06-20 is after coverage terminated on 2026-05-10. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-020905	2026-05-11	Summit Community Hospital	$3,738.00	Denied
CLM-2026-010430	2026-01-14	Northgate Medical Group	$331.00	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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity