Claims workbench/CLM-2026-018102

Institutional claim · UB-04 · EDI 837I

CLM-2026-018102

Unity Imaging Center, Radiology. Service 2026-06-09 at outpatient hospital (POS 22). Received 2026-06-22.

PendedOut of networkIdentity on hold: CASE-001969

Billed

$1,900.00

2 lines

Allowed

$855.00

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: Ahmed Sanders
Member ID: UHC-57673-12
Date of birth: 1950-04-11
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-407569
Relationship: Self

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-5989
Coverage period: 2021-12-01 to present
Deductible: $1,228.86 of $3,500.0035%
Out-of-pocket maximum: $2,079.73 of $10,500.0020%
Copays: office $25.00, specialist $75.00, emergency $150.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Unity Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 8566952718
Network: Out of network
Rendering NPI: 8566952718
Location: Miami, FL · TIN 34-7730969
Authorisation / referral: PA2025340017 / 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	77067 rev 0403	Screening mammography, bilateral	—	1	1	$397.00	$178.65	—	—	PendedIDQ
2	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1,2	$1,503.00	$676.35	—	—	PendedIDQ
Totals						$1,900.00	$855.00	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-813806
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-001969; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Pass		Active on 2026-06-09: NULL (PPO), effective 2021-12-01.
Timely filing	Pass		Received 13 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025340017 on file for 74177.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Review	CO50	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: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Unity Imaging Center2026-06-09 18:28
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

Prior auth letterPA2025340017_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-06-09 to 2026-09-07.
Itemized billitemized_PA-813806.pdf4 pages
Itemised statement totalling $1900.00 across 2 lines.

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-001969; payment withheld until the identity is confirmed. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.

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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue Member identity