Claims workbench/CLM-2026-016694

Institutional claim · UB-04 · EDI 837I

CLM-2026-016694

Riverside Diagnostic Imaging, Radiology. Service 2026-09-12 at outpatient hospital (POS 22). Received 2026-10-01.

Denied

Billed

$4,607.00

2 lines

Allowed

$2,533.85

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Kayla Gardner
Member ID: UHC-87728-37
Date of birth: 1947-02-13
Identity: Verified3 records, confidence 0.96
Claim record: CLMCLM-413025
Relationship: Self, Jacksonville, FL

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-9682
Coverage period: 2025-02-01 to present
Deductible: $662.83 of $2,500.0027%
Out-of-pocket maximum: $3,833.73 of $10,000.0038%
Copays: office $25.00, specialist $50.00, emergency $150.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI: 6802768252
Network: In network
Rendering NPI: 6802768252
Location: Scottsdale, AZ · TIN 85-0998777
Authorisation / referral: none / 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	$3,343.00	$1,838.65	—	—	DeniedCO197
2	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1,2	$1,264.00	$695.20	—	—	DeniedCO197
Totals						$4,607.00	$2,533.85	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
2. R07.9 Chest pain, unspecified
3. M25.561 Pain in right knee

Claim header

Patient account: PA-466761
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-011760 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2026-09-12: MEDICARE-ADV-B (MA), effective 2025-02-01.
Timely filing	Pass		Received 19 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	70553, 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent
Provider network	Pass		In-network provider Riverside Diagnostic Imaging (6802768252).
Medical necessity	Review	CO50	70553, 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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Diagnostic Imaging2026-09-12 14:32
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-10-01 01:04
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-01 10:52
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Itemized billitemized_PA-466761.pdf7 pages
Itemised statement totalling $4607.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Prior authorisation: 70553, 74177 require precertification; no authorisation number on the claim. Medical necessity: 70553, 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-2026-028270	2026-01-29	Pinecrest Family Practice	$276.00	Approved

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

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity