Claims workbench/CLM-2026-016315

Institutional claim · UB-04 · EDI 837I

CLM-2026-016315

Valley Imaging Center, Radiology. Service 2026-02-20 at outpatient hospital (POS 22). Received 2026-03-17.

PendedIdentity on hold: CASE-001074

Billed

$2,750.00

2 lines

Allowed

$1,512.50

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Samuel Wilson
Member ID: none on golden record
Date of birth: 2003-04-10
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-405804
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: - PPO group GRP-6879
Coverage period: 2022-09-01 to present
Deductible: $325.65 of $1,000.0033%
Out-of-pocket maximum: $72.39 of $2,000.004%
Copays: office $40.00, specialist $40.00, emergency $150.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Valley Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 5964910181
Network: In network
Rendering NPI: 7696270280 (Valley Imaging Center)
Location: Austin, TX · TIN 60-0192260
Authorisation / referral: PA2026474179 / 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	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1	$2,380.00	$1,309.00	—	—	PendedIDQ
2	76700 rev 0402	Ultrasound abdomen, complete	—	1	2	$370.00	$203.50	—	—	PendedIDQ
Totals						$2,750.00	$1,512.50	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal
2. R10.9 Unspecified abdominal pain

Claim header

Patient account: PA-250606
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-001074; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-02-20: - (PPO), effective 2022-09-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 25 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-016314, billed by a different provider. Possible duplicate
Prior authorisation	Pass		Authorisation PA2026474179 on file for 74177.
Provider network	Pass		In-network provider Valley Imaging Center (5964910181).
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: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Imaging Center2026-02-20 13:21
Follow-up for pain in right knee. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-03-17 06:19
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-17 10:28
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2026474179_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-02-20 to 2026-05-21.
Itemized billitemized_PA-250606.pdf9 pages
Itemised statement totalling $2750.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-001074; payment withheld until the identity is confirmed. Eligibility: Active on 2026-02-20: - (PPO), effective 2022-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. Duplicate check: Same member, date of service and procedures as CLM-2026-016314, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-016314	2026-02-20	Valley Imaging Center	$2,750.00	Pended

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

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: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity