Claims workbench/CLM-2026-015937

Institutional claim · UB-04 · EDI 837I

CLM-2026-015937

Northgate Imaging Center, Radiology. Service 2025-12-15 at outpatient hospital (POS 22). Received 2026-01-18.

Needs reviewReplacement of CLM-2026-015936Out of network

Billed

$2,069.00

2 lines

Allowed

$931.05

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

REPL, CO50

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Peter Kelly
Member ID: UHC-28833-25
Date of birth: 1981-07-09
Identity: Verified5 records, confidence 0.96
Claim record: CLMCLM-407678
Relationship: Self, Las Vegas, NV

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-3857
Coverage period: 2021-11-01 to present
Deductible: $2,191.37 of $3,500.0063%
Out-of-pocket maximum: $654.94 of $10,500.006%
Copays: office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 3050464585
Network: Out of network
Rendering NPI: 3050464585
Location: San Diego, CA · TIN 61-2250278
Authorisation / referral: PA2026700257 / 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	$364.00	$163.80	—	—	Review
2	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1	$1,705.00	$767.25	—	—	Review
Totals						$2,069.00	$931.05	—	—

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-697179
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-002230 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2025-12-15: OPTIONS-PPO (PPO), effective 2021-11-01.
Timely filing	Pass		Received 34 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-015936; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		Authorisation PA2026700257 on file for 74177.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Review	CO50	74177 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 2026-10-21 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: Northgate Imaging Center2025-12-15 18:39
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-01-18 00:20
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.

Attachments

Documents received with the claim

Prior auth letterPA2026700257_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2025-12-15 to 2026-03-15.
Itemized billitemized_PA-697179.pdf4 pages
Itemised statement totalling $2069.00 across 2 lines.
Corrected claimcorrected_CLM-2026-015936.pdf1 page
Provider cover letter requesting replacement of CLM-2026-015936.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-015936; the original must be voided when this adjudicates. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Medical necessity: 74177 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-2026-021905	2026-02-06	Harbor Medical Group	$249.00	Approved
CLM-2026-008447	2025-12-25	Northgate Internal Medicine Associates	$296.00	Approved
CLM-2026-015936	2025-12-15	Northgate Imaging Center	$2,069.00	Needs review

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

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

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

Approvedscenario: Replacement

Replacement claim supersedes the original.

Review queue Member identity