Claims workbench/CLM-2026-023152

Institutional claim · UB-04 · EDI 837I

CLM-2026-023152

Desert Imaging Center, Radiology. Service 2026-06-14 at outpatient hospital (POS 22). Received 2026-07-17.

PendedIdentity on hold: CASE-003150

Billed

$1,950.00

3 lines

Allowed

$1,072.50

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Andrew Bennett
Member ID: none on golden record
Date of birth: 1959-07-03
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-409559
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: SELECT-EPO EPO group GRP-8077
Coverage period: 2024-08-01 to present
Deductible: $151.66 of $1,000.0015%
Out-of-pocket maximum: $136.43 of $2,000.007%
Copays: office $25.00, specialist $50.00, emergency $350.00
Physical therapy visits: 4 of 20 used

Provider

Billing and rendering

Billing provider: Desert Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 7235030955
Network: In network
Rendering NPI: 7235030955
Location: San Diego, CA · TIN 44-8505123
Authorisation / referral: PHONE-887711 / 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	76700 rev 0402	Ultrasound abdomen, complete	—	1	1	$329.00	$180.95	—	—	PendedIDQ
2	77067 rev 0403	Screening mammography, bilateral	—	1	2	$318.00	$174.90	—	—	PendedIDQ
3	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1	$1,303.00	$716.65	—	—	PendedIDQ
Totals						$1,950.00	$1,072.50	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal
2. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-964365
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

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-003150; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-06-14: SELECT-EPO (EPO), effective 2024-08-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 33 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Review	CO197	Authorisation reference “PHONE-887711” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent
Provider network	Pass		In-network provider Desert Imaging Center (7235030955).
Medical necessity	Pass		Diagnosis supports the procedures billed.
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Desert Imaging Center2026-06-14 10:26
Established patient presents with pain in right knee; 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 system2026-07-17 02:24
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-964365.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Itemized billitemized_PA-964365.pdf4 pages
Itemised statement totalling $1950.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-003150; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-14: SELECT-EPO (EPO), effective 2024-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. Prior authorisation: Authorisation reference “PHONE-887711” does not match the utilisation-management format; must be confirmed before payment.

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

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity