Claims workbench/CLM-2026-019659

Institutional claim · UB-04 · EDI 837I

CLM-2026-019659

Sunrise Imaging Center, Radiology. Service 2026-03-28 at outpatient hospital (POS 22). Received 2026-04-15.

Needs review

Billed

$1,951.00

2 lines

Allowed

$1,073.05

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO50

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Dorothy Bradley
Member ID: UHC-61130-89
Date of birth: 1952-09-12
Identity: Verified6 records, confidence 1.00
Claim record: CLMCLM-421260
Relationship: Self, Seattle, WA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-3375
Coverage period: 2025-11-01 to present
Deductible: $862.06 of $1,000.0086%
Out-of-pocket maximum: $811.68 of $2,000.0041%
Copays: office $20.00, specialist $40.00, emergency $150.00
Physical therapy visits: 9 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 9418627425
Network: In network
Rendering NPI: 9418627425
Location: Mesa, AZ · TIN 78-4773350
Authorisation / referral: PA2026371208 / 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	71046 rev 0320	Chest X-ray, two views	—	1	1	$152.00	$83.60	—	—	Review
2	74177 rev 0350	CT abdomen and pelvis with contrast	25	1	1,2	$1,799.00	$989.45	—	—	Review
Totals						$1,951.00	$1,073.05	—	—

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-966786
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-001864 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-03-28: CHOICE-PLUS-PPO (PPO), effective 2025-11-01.
Timely filing	Pass		Received 18 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026371208 on file for 74177.
Provider network	Pass		In-network provider Sunrise Imaging Center (9418627425).
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Imaging Center2026-03-28 10:32
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

Prior auth letterPA2026371208_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-03-28 to 2026-06-26.
Itemized billitemized_PA-966786.pdf4 pages
Itemised statement totalling $1951.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Medical necessity: 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-2026-002668	2026-09-28	Heritage Community Hospital	$696.00	Approved
CLM-2026-023324	2026-08-01	Heritage Primary Care Associates	$59.00	Approved
CLM-2026-019270	2026-03-24	Sunrise Dermatology Clinic	$408.00	Approved
CLM-2026-008213	2025-12-17	Heritage Medical Group	$42.00	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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue Member identity