Claims workbench/CLM-2026-014740

Institutional claim · UB-04 · Provider portal

CLM-2026-014740

Canyon Diagnostic Imaging, Radiology. Service 2026-03-22 at outpatient hospital (POS 22). Received 2026-04-21.

DeniedIdentity on hold: CASE-003790

Billed

$449.00

1 line

Allowed

$246.95

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Carlos Mendez
Member ID: none on golden record
Date of birth: 1967-01-27
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-409410
Relationship: Self, San Antonio, TX

Coverage and accumulators

Found by name and date of birth

Plan: NAVIGATE-HMO HMO group GRP-7804
Coverage period: 2022-11-01 to present
Deductible: $1,341.79 of $3,500.0038%
Out-of-pocket maximum: $1,732.45 of $7,000.0025%
Copays: office $40.00, specialist $50.00, emergency $150.00
Physical therapy visits: 10 of 20 used

Provider

Billing and rendering

Billing provider: Canyon Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI: 8055565153
Network: In network
Rendering NPI: 8055565153
Location: Atlanta, GA · TIN 44-7708549
Authorisation / referral: none / REF168561

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	76700 rev 0402	Ultrasound abdomen, complete	—	1	1	$449.00	$246.95	—	—	DeniedCO18
Totals						$449.00	$246.95	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal
2. M25.561 Pain in right knee
3. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-293943
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-003790; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-03-22: NAVIGATE-HMO (HMO), effective 2022-11-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 30 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-014739: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Canyon Diagnostic Imaging (8055565153).
Medical necessity	Pass		Diagnosis supports the procedures billed.
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: Canyon Diagnostic Imaging2026-03-22 09:07
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-04-21 00:44
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

Attachments

Documents received with the claim

Itemized billitemized_PA-293943.pdf2 pages
Itemised statement totalling $449.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Member identity: Member record is in open steward case CASE-003790; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-22: NAVIGATE-HMO (HMO), effective 2022-11-01. Coverage found by name and date of birth because the claim carried no usable member ID. Duplicate check: Exact duplicate of CLM-2026-014739: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-014739	2026-03-22	Canyon Diagnostic Imaging	$449.00	Pended

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity