CLM-2026-016613
Riverside Diagnostic Imaging, Radiology. Service 2025-12-07 at outpatient hospital (POS 22). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Shirley Bennnett
- Member ID
- none on golden record
- Date of birth
- 1955-08-22
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417175
- Relationship
- Self, Plano, TX
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Riverside Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 6802768252
- Network
- In network
- Rendering NPI
- 6802768252
- Location
- Scottsdale, AZ · TIN 85-0998777
- Authorisation / referral
- PHONE-161489 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,015.00 | $1,108.25 | — | — | PendedIDQ |
| Totals | $2,015.00 | $1,108.25 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-501009
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
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-000960; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Review | CO197 | Authorisation reference “PHONE-161489” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent |
| Provider network | Pass | In-network provider Riverside Diagnostic Imaging (6802768252). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Diagnostic Imaging2025-12-07 13:27
Patient seen for headache, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-11 04:40
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-501009.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-501009.pdf7 pages
Itemised statement totalling $2015.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000960; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Prior authorisation: Authorisation reference “PHONE-161489” does not match the utilisation-management format; must be confirmed before payment.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.