Claims workbench/CLM-2026-016732
Institutional claim · UB-04 · EDI 837I

CLM-2026-016732

Riverside Diagnostic Imaging, Radiology. Service 2026-08-26 at outpatient hospital (POS 22). Received 2026-09-11.

PendedIdentity on hold: CASE-004310
Billed
$255.00
1 line
Allowed
$140.25
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Maria Ortiz
Member ID
none on golden record
Date of birth
1961-08-02
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-408872
Relationship
Child, Nashville, TN

Coverage and accumulators

Eligibility

No coverage segment found for this member.

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 / REF299864

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
177067
rev 0403
Screening mammography, bilateral—11$255.00$140.25——PendedIDQ
Totals$255.00$140.25——
Diagnoses (ICD-10-CM)
  • 1. R51.9 Headache, unspecifiedprincipal
  • 2. M25.561 Pain in right knee
Claim header
Patient account
PA-465526
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-004310; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 16 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Riverside Diagnostic Imaging (6802768252).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Riverside Diagnostic Imaging2026-08-26 14:05

    Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-465526.pdf6 pages

    Itemised statement totalling $255.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-004310; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

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
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: Clean

Clean claim, priced at contract rate.

Review queueMember identity