Claims workbench/CLM-2026-015028
Institutional claim · UB-04 · EDI 837I

CLM-2026-015028

Sunrise Imaging Center, Radiology. Service 2025-12-23 at outpatient hospital (POS 22). Received 2026-01-08.

Needs reviewOut of network
Billed
$2,822.00
2 lines
Allowed
$1,269.90
if approved
Plan pays
—
Needs review
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Review
CO50
Decided by
Nobody yet
open

Member

Resolved through the identity graph

Member
Emma Simpson
Member ID
UHC-49747-10
Date of birth
1966-03-13
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-404805
Relationship
Spouse, Charlotte, NC

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-8522
Coverage period
2025-08-01 to present
Deductible
$2,659.64 of $3,500.0076%
Out-of-pocket maximum
$3,001.08 of $14,000.0021%
Copays
office $30.00, specialist $40.00, emergency $350.00
Physical therapy visits
3 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise Imaging Center
Radiology · taxonomy 2085R0202X
NPI
9630195771
Network
Out of network
Rendering NPI
9630195771
Location
Dallas, TX · TIN 60-5457120
Authorisation / referral
PA2026163810 / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
176700
rev 0402
Ultrasound abdomen, complete—11$574.00$258.30——Review
270553
rev 0610
MRI brain with and without contrast—11,2$2,248.00$1,011.60——Review
Totals$2,822.00$1,269.90——
Diagnoses (ICD-10-CM)
  • 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
  • 2. R07.9 Chest pain, unspecified
Claim header
Patient account
PA-519369
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 identityPassAttached to MBR-002574 (verified, link confidence 0.99).
EligibilityPassActive on 2025-12-23: OPTIONS-PPO (PPO), effective 2025-08-01.
Timely filingPassReceived 16 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026163810 on file for 70553.
Provider networkNoteOut-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessityReviewCO5070553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Not medically necessary per payer policy
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Sunrise Imaging Center2025-12-23 13:35

    Patient seen for encounter for screening mammogram for malignant neoplasm of breast.

Attachments

Documents received with the claim

  • Prior auth letterPA2026163810_approval.pdf2 pages

    Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2025-12-23 to 2026-03-23.

  • Itemized billitemized_PA-519369.pdf5 pages

    Itemised statement totalling $2822.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineReview2026-10-21 13:43
    Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
  2. AI recommendationPended2026-10-21 14:15
    The claim includes an MRI brain with and without contrast (70553) billed with a routine diagnosis (Z12.31). The rules engine flagged this service for medical necessity (CO50). The clinical note provided by the provider only mentions the screening mammogram and does not provide details to support the necessity of the MRI. Therefore, the claim is pended to verify if the clinical notes support the medical necessity of the MRI.
  3. AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 44361c30

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode

Pendedconfidence 0.80 Validated
  • CO50 Not medically necessary per payer policy

The claim includes an MRI brain with and without contrast (70553) billed with a routine diagnosis (Z12.31). The rules engine flagged this service for medical necessity (CO50). The clinical note provided by the provider only mentions the screening mammogram and does not provide details to support the necessity of the MRI. Therefore, the claim is pended to verify if the clinical notes support the medical necessity of the MRI.

Questions for the examiner
  • Verify if the clinical notes support the medical necessity of the MRI brain with and without contrast (70553) for the given diagnosis.
Evidence cited: [C][DX][L2][R-clinical_edit][N1]
Latency
2,268 ms
Tokens
1,333 in / 188 out
Cost
$0.0017
Input hash d08b83d3f7b6e3f1… · identifiers withheld from the model: name, dob, member_id

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Pre-filled from the AI recommendation. Change anything before you record it.
Outcome
Reason codes *
  • CO50 Not medically necessary per payer policy
475 characters
ExaminerR. Patel (Claims Examiner II)
Will apply: pend

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity