Claims workbench/CLM-2026-012305

Institutional claim · UB-04 · EDI 837I

CLM-2026-012305

Valley Regional Medical Center, Emergency Medicine. Service 2026-07-08 at outpatient hospital (POS 22). Received 2026-07-10.

Pended

Billed

$3,121.00

1 line

Allowed

$1,716.55

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Pend

CO16

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-7506
Coverage period: 2024-05-01 to present
Deductible: $577.33 of $1,000.0058%
Out-of-pocket maximum: $1,558.07 of $4,000.0039%
Copays: office $20.00, specialist $40.00, emergency $150.00
Physical therapy visits: 15 of 20 used

Provider

Billing and rendering

Billing provider: Valley Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 2408607978
Network: In network
Rendering NPI: 2408607978
Location: Austin, TX · TIN 89-0699789
Authorisation / referral: PA2026719566 / 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	$3,121.00	$1,716.55	—	—	PendedCO16
Totals						$3,121.00	$1,716.55	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. R55 Syncope and collapse
3. J18.9 Pneumonia, unspecified organism

Claim header

Patient account: PA-358810
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	Fail	CO16	Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication
Eligibility	Pass		Active on 2026-07-08: NULL (PPO), effective 2024-05-01.
Timely filing	Pass		Received 2 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026719566 on file for 70553.
Provider network	Pass		In-network provider Valley Regional Medical Center (2408607978).
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: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Regional Medical Center2026-07-08 12:38
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. 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 system2026-07-10 00:32
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-10 11:48
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2026719566_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-08 to 2026-10-06.
Itemized billitemized_PA-358810.pdf9 pages
Itemised statement totalling $3121.00 across 1 line.
Medical recordrecords_PA-358810.pdf18 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 enginePended2026-10-21 13:43
Member identity: Claim record is not attached to a resolved identity. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.

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

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

Approvedscenario: Dx mismatch

Notes document medical necessity.

Review queue