Claims workbench/CLM-2026-017827

Institutional claim · UB-04 · Paper

CLM-2026-017827

Sunrise Diagnostic Imaging, Radiology. Service 2026-08-27 at outpatient hospital (POS 22). Received 2026-09-15.

PendedIdentity on hold: CASE-002830

Billed

$3,153.00

1 line

Allowed

$1,734.15

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Rachel Young
Member ID: UHC-25987-45
Date of birth: 1961-08-26
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-432745
Relationship: Self, Phoenix, AZ

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-3415
Coverage period: 2023-05-01 to present
Deductible: $85.81 of $1,000.009%
Out-of-pocket maximum: $1,668.65 of $4,000.0042%
Copays: office $30.00, specialist $60.00, emergency $150.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI: 8125654300
Network: In network
Rendering NPI: 8125654300
Location: Scottsdale, AZ · TIN 88-4094032
Authorisation / referral: PA2025261821 / 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	$3,153.00	$1,734.15	—	—	PendedIDQ
Totals						$3,153.00	$1,734.15	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal
2. R51.9 Headache, unspecified

Claim header

Patient account: PA-640968
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	Fail	IDQ	Member record is in open steward case CASE-002830; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Pass		Active on 2026-08-27: SELECT-EPO (EPO), effective 2023-05-01.
Timely filing	Pass		Received 19 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025261821 on file for 70553.
Provider network	Pass		In-network provider Sunrise Diagnostic Imaging (8125654300).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Patient seen for unspecified abdominal pain. Note dictated; signature pending.”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within 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: Sunrise Diagnostic Imaging2026-08-27 16:06
Patient seen for unspecified abdominal pain. Note dictated; signature pending.
SystemSystem: Claims system2026-09-15 05:46
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-15 08:43
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2025261821_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-27 to 2026-11-25.
Itemized billitemized_PA-640968.pdf7 pages
Itemised statement totalling $3153.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-002830; payment withheld until the identity is confirmed. Completeness: Documentation incomplete: “Patient seen for unspecified abdominal pain. Note dictated; signature pending.”.

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

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity