Claims workbench/CLM-2026-021399
Institutional claim · UB-04 · EDI 837I

CLM-2026-021399

Desert Diagnostic Imaging, Radiology. Service 2026-07-01 at outpatient hospital (POS 22). Received 2026-07-03.

Pended
Billed
$1,443.00
2 lines
Allowed
$793.65
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Amanda Richards
Member ID
none on golden record
Date of birth
1947-04-20
Identity
Verified2 records, confidence 0.97
Claim record
CLMCLM-428955
Relationship
Self, Jacksonville, FL

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Desert Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI
3515366425
Network
In network
Rendering NPI
3515366425
Location
Phoenix, AZ · TIN 68-2801174
Authorisation / referral
PA2026005180 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
171046
rev 0320
Chest X-ray, two views—11$112.00$61.60——PendedN30
274177
rev 0350
CT abdomen and pelvis with contrast—12$1,331.00$732.05——PendedN30
Totals$1,443.00$793.65——
Diagnoses (ICD-10-CM)
  • 1. R10.9 Unspecified abdominal painprincipal
  • 2. R07.9 Chest pain, unspecified
Claim header
Patient account
PA-567558
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-037140 (verified, link confidence 0.97).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 2 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026005180 on file for 74177.
Provider networkPassIn-network provider Desert Diagnostic Imaging (3515366425).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Desert Diagnostic Imaging2026-07-01 18:37

    Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Prior auth letterPA2026005180_approval.pdf2 pages

    Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-07-01 to 2026-09-29.

  • Itemized billitemized_PA-567558.pdf7 pages

    Itemised statement totalling $1443.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Eligibility: No coverage segment found for the member ID on this claim.

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
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 queueMember identity