Claims workbench/CLM-2026-013383

Institutional claim · UB-04 · EDI 837I

CLM-2026-013383

Cornerstone Imaging Center, Radiology. Service 2025-09-08 at outpatient hospital (POS 22). Received 2026-03-10.

Denied

Billed

$5,548.00

3 lines

Allowed

$3,051.40

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Bobby Carroll
Member ID: UHC-95688-41
Date of birth: 1953-10-03
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-424922
Relationship: Spouse, Charlotte, NC

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-6245
Coverage period: 2021-02-01 to present
Deductible: $289.47 of $500.0058%
Out-of-pocket maximum: $246.46 of $1,500.0016%
Copays: office $20.00, specialist $75.00, emergency $250.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Cornerstone Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 9835477198
Network: In network
Rendering NPI: 9835477198
Location: Tampa, FL · TIN 89-9420622
Authorisation / referral: PA2025134844 / 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	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1	$1,861.00	$1,023.55	—	—	DeniedCO29
2	70553 rev 0610	MRI brain with and without contrast	—	1	1	$3,503.00	$1,926.65	—	—	DeniedCO29
3	71046 rev 0320	Chest X-ray, two views	25	1	1	$184.00	$101.20	—	—	DeniedCO29
Totals						$5,548.00	$3,051.40	—	—

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-991756
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-018647 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-09-08: MEDICARE-ADV-B (MA), effective 2021-02-01.
Timely filing	Fail	CO29	Received 183 days after the last date of service (limit 90). Time limit for filing has expired
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025134844 on file for 74177, 70553.
Provider network	Pass		In-network provider Cornerstone Imaging Center (9835477198).
Medical necessity	Review	CO50	74177, 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	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: Cornerstone Imaging Center2025-09-08 12:06
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-03-10 00:43
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

Attachments

Documents received with the claim

Prior auth letterPA2025134844_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-09-08 to 2025-12-07.
Itemized billitemized_PA-991756.pdf3 pages
Itemised statement totalling $5548.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Timely filing: Received 183 days after the last date of service (limit 90). Medical necessity: 74177, 70553 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-2026-026907	2026-08-24	Sunrise Physical Therapy	$336.00	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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity