Claims workbench/CLM-2026-012918

Institutional claim · UB-04 · EDI 837I

CLM-2026-012918

Northgate Imaging Center, Radiology. Service 2026-08-24 at outpatient hospital (POS 22). Received 2026-10-07.

Needs reviewReplacement of CLM-2026-012917Out of network

Billed

$2,863.00

3 lines

Allowed

$1,288.35

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

REPL, CO50

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Megan Williams
Member ID: UHC-64753-11
Date of birth: 1939-04-10
Identity: Verified2 records, confidence 1.00
Claim record: CLMCLM-406999
Relationship: Spouse, Phoenix, AZ

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-9559
Coverage period: 2022-04-01 to present
Deductible: $1,120.19 of $2,500.0045%
Out-of-pocket maximum: $1,264.81 of $7,500.0017%
Copays: office $20.00, specialist $50.00, emergency $350.00
Physical therapy visits: 3 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 3050464585
Network: Out of network
Rendering NPI: 3050464585
Location: San Diego, CA · TIN 61-2250278
Authorisation / referral: PA2026145456 / 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	77067 rev 0403	Screening mammography, bilateral	—	1	1	$370.00	$166.50	—	—	Review
2	71046 rev 0320	Chest X-ray, two views	—	1	1,2	$178.00	$80.10	—	—	Review
3	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1,2	$2,315.00	$1,041.75	—	—	Review
Totals						$2,863.00	$1,288.35	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
2. R10.9 Unspecified abdominal pain

Claim header

Patient account: PA-121355
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-031715 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-08-24: N/A (PPO), effective 2022-04-01.
Timely filing	Pass		Received 44 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-012917; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		Authorisation PA2026145456 on file for 74177.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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 2026-10-21 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: Northgate Imaging Center2026-08-24 13:33
Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-10-07 00:55
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-07 14:48
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2026145456_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-08-24 to 2026-11-22.
Itemized billitemized_PA-121355.pdf6 pages
Itemised statement totalling $2863.00 across 3 lines.
Corrected claimcorrected_CLM-2026-012917.pdf1 page
Provider cover letter requesting replacement of CLM-2026-012917.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-012917; the original must be voided when this adjudicates. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. 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-2026-012917	2026-08-24	Northgate Imaging Center	$2,863.00	Needs review
CLM-2026-015867	2026-04-15	Cornerstone Clinical Laboratories	$42.00	Approved

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

Approvedscenario: Replacement

Replacement claim supersedes the original.

Review queue Member identity