Claims workbench/CLM-2026-018169

Institutional claim · UB-04 · EDI 837I

CLM-2026-018169

Sunrise Imaging Center, Radiology. Service 2026-05-25 at outpatient hospital (POS 22). Received 2026-06-03.

Needs reviewOut of network

Billed

$3,576.00

1 line

Allowed

$1,609.20

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Linda Obrien
Member ID: UHC-52970-96
Date of birth: 1944-04-01
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-407188
Relationship: Self, Nashville, TN

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-6426
Coverage period: 2022-05-01 to present
Deductible: $259.18 of $500.0052%
Out-of-pocket maximum: $113.38 of $1,000.0011%
Copays: office $30.00, specialist $50.00, emergency $150.00
Physical therapy visits: 16 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 9630195771
Network: Out of network
Rendering NPI: 9630195771
Location: Dallas, TX · TIN 60-5457120
Authorisation / referral: PA2026826711 / 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	$3,576.00	$1,609.20	—	—	Review
Totals						$3,576.00	$1,609.20	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal

Claim header

Patient account: PA-248104
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-033382 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-05-25: MEDICARE-ADV-A (MA), effective 2022-05-01.
Timely filing	Pass		Received 9 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026826711 on file for 70553.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Imaging Center2026-05-25 18:02
Patient seen for unspecified abdominal pain. Note dictated; signature pending.
SystemSystem: Claims system2026-06-03 04:33
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-03 13:12
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2026826711_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-05-25 to 2026-08-23.
Itemized billitemized_PA-248104.pdf5 pages
Itemised statement totalling $3576.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Patient seen for unspecified abdominal pain. Note dictated; signature pending.”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-022954	2026-05-06	Canyon GI Associates	$5,211.00	Denied
CLM-2026-023131	2026-06-28	Unity Reference Lab	$76.00	Approved
CLM-2026-030001	2026-05-16	Riverside Regional Medical Center	$1,067.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

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