Claims workbench/CLM-2026-019977

Institutional claim · UB-04 · EDI 837I

CLM-2026-019977

Meadow Imaging Center, Radiology. Service 2026-04-13 at outpatient hospital (POS 22). Received 2026-05-28.

Needs review

Billed

$3,017.00

1 line

Allowed

$1,659.35

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

CO197, CO50

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Roger Contreras
Member ID: UHC-06935-90
Date of birth: 1975-05-15
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-431374
Relationship: Self, San Diego, CA

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-4832
Coverage period: 2023-10-01 to present
Deductible: $763.34 of $1,000.0076%
Out-of-pocket maximum: $1,033.20 of $3,000.0034%
Copays: office $30.00, specialist $40.00, emergency $350.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Meadow Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 4402940280
Network: In network
Rendering NPI: 4402940280
Location: San Diego, CA · TIN 30-5345877
Authorisation / referral: PHONE-165218 / 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	$3,017.00	$1,659.35	—	—	Review
Totals						$3,017.00	$1,659.35	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
2. R51.9 Headache, unspecified
3. R10.9 Unspecified abdominal pain

Claim header

Patient account: PA-381769
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-027954 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-04-13: MEDICARE-ADV-B (MA), effective 2023-10-01.
Timely filing	Pass		Received 45 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Review	CO197	Authorisation reference “PHONE-165218” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent
Provider network	Pass		In-network provider Meadow Imaging Center (4402940280).
Medical necessity	Review	CO50	70553 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: Meadow Imaging Center2026-04-13 11:06
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
SystemSystem: Claims system2026-05-28 01:03
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-28 12:59
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-381769.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Itemized billitemized_PA-381769.pdf5 pages
Itemised statement totalling $3017.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Prior authorisation: Authorisation reference “PHONE-165218” does not match the utilisation-management format; must be confirmed before payment. Medical necessity: 70553 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

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

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity