Claims workbench/CLM-2026-016019

Institutional claim · UB-04 · EDI 837I

CLM-2026-016019

Canyon Diagnostic Imaging, Radiology. Service 2026-06-04 at outpatient hospital (POS 22). Received 2026-07-15.

Needs review

Billed

$2,750.00

2 lines

Allowed

$1,512.50

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

CO50, CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Virginia Berry
Member ID: UHC-58654-72
Date of birth: 1960-09-23
Identity: Verified5 records, confidence 0.97
Claim record: CLMCLM-406513
Relationship: Self, San Diego, CA

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-8779
Coverage period: 2025-03-01 to present
Deductible: $392.02 of $1,500.0026%
Out-of-pocket maximum: $518.60 of $3,000.0017%
Copays: office $20.00, specialist $60.00, emergency $250.00
Physical therapy visits: 1 of 20 used

Provider

Billing and rendering

Billing provider: Canyon Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI: 6871661313
Network: In network
Rendering NPI: 6871661313
Location: Tampa, FL · TIN 87-4174394
Authorisation / referral: PA2025341076 / REF864452

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	59	1	1	$521.00	$286.55	—	—	Review
2	74177 rev 0350	CT abdomen and pelvis with contrast	59	1	1	$2,229.00	$1,225.95	—	—	Review
Totals						$2,750.00	$1,512.50	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal

Claim header

Patient account: PA-800522
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-015241 (verified, link confidence 0.97).
Eligibility	Pass		Active on 2026-06-04: CORE-HMO (HMO), effective 2025-03-01.
Timely filing	Pass		Received 41 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025341076 on file for 74177.
Provider network	Pass		In-network provider Canyon Diagnostic Imaging (6871661313).
Medical necessity	Review	CO50	74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Canyon Diagnostic Imaging2026-06-04 14:40
Patient seen for encounter for screening mammogram for malignant neoplasm of breast. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
SystemSystem: Claims system2026-07-15 04:49
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-15 16:47
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2025341076_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2026-06-04 to 2026-09-02.
Itemized billitemized_PA-800522.pdf3 pages
Itemised statement totalling $2750.00 across 2 lines.
Medical recordrecords_PA-800522.pdf9 pages
Operative note describing procedures at two distinct anatomical sites.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-023061	2026-08-07	Canyon Clinical Laboratories	$84.00	Approved
CLM-2026-019747	2026-08-09	Heritage Community Hospital	$213.00	Approved
CLM-2026-031366	2026-01-15	Harbor Rehabilitation Center	$210.00	Approved

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: Unbundling supported

Modifier 59 supported: distinct anatomical site documented.

Review queue Member identity