Claims workbench/CLM-2026-015188

Institutional claim · UB-04 · EDI 837I

CLM-2026-015188

Sunrise Imaging Center, Radiology. Service 2026-09-29 at outpatient hospital (POS 22). Received 2026-10-17.

DeniedOut of network

Billed

$2,395.00

2 lines

Allowed

$1,077.75

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Jacqueline Willis
Member ID: UHC-69078-97
Date of birth: 2003-09-05
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-401811
Relationship: Self, San Diego, CA

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-0166
Coverage period: 2024-04-01 to 2026-02-12
Deductible: $561.22 of $1,000.0056%
Out-of-pocket maximum: $639.59 of $2,000.0032%
Copays: office $40.00, specialist $40.00, emergency $350.00
Physical therapy visits: 6 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: PA2026415567 / 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	76700 rev 0402	Ultrasound abdomen, complete	—	1	1	$400.00	$180.00	—	—	DeniedCO27
2	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1	$1,995.00	$897.75	—	—	DeniedCO27
Totals						$2,395.00	$1,077.75	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal

Claim header

Patient account: PA-703488
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

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-041961 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-09-29 is after coverage terminated on 2026-02-12. Expenses incurred after coverage terminated
Timely filing	Pass		Received 18 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026415567 on file for 74177.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Imaging Center2026-09-29 13:47
Patient seen for unspecified abdominal pain.
SystemSystem: Claims system2026-10-17 02:52
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-17 14:56
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2026415567_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-09-29 to 2026-12-28.
Itemized billitemized_PA-703488.pdf8 pages
Itemised statement totalling $2395.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-09-29 is after coverage terminated on 2026-02-12. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-014664	2026-09-08	Pinecrest Bone and Joint Center	$222.00	Denied
CLM-2026-000643	2026-08-16	Harbor Physical Therapy	$303.00	Denied

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity