Claims workbench/CLM-2026-014697
Institutional claim · UB-04 · Provider portal

CLM-2026-014697

Riverside Imaging Center, Radiology. Service 2026-08-18 at outpatient hospital (POS 22). Received 2026-09-23.

PendedIdentity on hold: CASE-002937
Billed
$2,666.00
2 lines
Allowed
$1,466.30
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Andrea Patel
Member ID
none on golden record
Date of birth
2009-04-01
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-417673
Relationship
Spouse, Columbus, OH

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Riverside Imaging Center
Radiology · taxonomy 2085R0202X
NPI
7427092680
Network
In network
Rendering NPI
7427092680
Location
Mesa, AZ · TIN 33-8428995
Authorisation / referral
PA2026016161 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
177067
rev 0403
Screening mammography, bilateral—11$238.00$130.90——PendedIDQ
270553
rev 0610
MRI brain with and without contrast—12$2,428.00$1,335.40——PendedIDQ
Totals$2,666.00$1,466.30——
Diagnoses (ICD-10-CM)
  • 1. R07.9 Chest pain, unspecifiedprincipal
  • 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
  • 3. R10.9 Unspecified abdominal pain
Claim header
Patient account
PA-477182
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-002937; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 36 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026016161 on file for 70553.
Provider networkPassIn-network provider Riverside Imaging Center (7427092680).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Riverside Imaging Center2026-08-18 17:38

    Patient seen for chest pain, unspecified.

Attachments

Documents received with the claim

  • Prior auth letterPA2026016161_approval.pdf2 pages

    Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-08-18 to 2026-11-16.

  • Itemized billitemized_PA-477182.pdf2 pages

    Itemised statement totalling $2666.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-002937; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.

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
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: Clean

Clean claim, priced at contract rate.

Review queueMember identity