Claims workbench/CLM-2026-024380

Institutional claim · UB-04 · EDI 837I

CLM-2026-024380

Unity Imaging Center, Radiology. Service 2026-09-14 at outpatient hospital (POS 22). Received 2026-10-05.

DeniedOut of network

Billed

$2,673.00

2 lines

Allowed

$1,202.85

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO27, CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Elijah Aguilar
Member ID: UHC-11836-39
Date of birth: 1996-12-19
Identity: Verified4 records, confidence 0.96
Claim record: CLMCLM-407442
Relationship: Self, Jacksonville, FL

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-3304
Coverage period: 2021-01-01 to 2026-03-19
Deductible: $29.68 of $500.006%
Out-of-pocket maximum: $176.20 of $1,000.0018%
Copays: office $30.00, specialist $50.00, emergency $150.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Unity Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 8566952718
Network: Out of network
Rendering NPI: 8566952718
Location: Miami, FL · TIN 34-7730969
Authorisation / referral: PA2026380076 / REF363435

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	59	1	1	$110.00	$49.50	—	—	DeniedCO27
2	70553 rev 0610	MRI brain with and without contrast	59	1	1	$2,563.00	$1,153.35	—	—	DeniedCO27
Totals						$2,673.00	$1,202.85	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal
2. R10.9 Unspecified abdominal pain

Claim header

Patient account: PA-764249
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-011291 (verified, link confidence 0.96).
Eligibility	Fail	CO27	Date of service 2026-09-14 is after coverage terminated on 2026-03-19. Expenses incurred after coverage terminated
Timely filing	Pass		Received 21 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026380076 on file for 70553.
Provider network	Fail	CO204	Billing provider 8566952718 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Unity Imaging Center2026-09-14 15:36
Follow-up for pain in right knee. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-10-05 03:16
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-05 11:54
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2026380076_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-09-14 to 2026-12-13.
Itemized billitemized_PA-764249.pdf2 pages
Itemised statement totalling $2673.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-09-14 is after coverage terminated on 2026-03-19. Provider network: Billing provider 8566952718 is out of network and the HMO plan has no out-of-network benefit. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-024649	2026-01-12	Heritage Clinical Laboratories	$90.00	Approved

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity