Claims workbench/CLM-2026-025908

Institutional claim · UB-04 · EDI 837I

CLM-2026-025908

Desert Imaging Center, Radiology. Service 2026-08-31 at outpatient hospital (POS 22). Received 2026-09-24.

Needs review

Billed

$2,184.00

2 lines

Allowed

$1,201.20

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

CO50

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Gregory Kennedy
Member ID: UHC-80526-03
Date of birth: 1991-09-21
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-422386
Relationship: Self, Dallas, TX

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-3592
Coverage period: 2024-10-01 to present
Deductible: $258.22 of $500.0052%
Out-of-pocket maximum: $297.03 of $1,000.0030%
Copays: office $40.00, specialist $75.00, emergency $350.00
Physical therapy visits: 12 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: PA2025099267 / 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	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1	$1,934.00	$1,063.70	—	—	Review
2	77067 rev 0403	Screening mammography, bilateral	—	1	2	$250.00	$137.50	—	—	Review
Totals						$2,184.00	$1,201.20	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
2. M25.561 Pain in right knee
3. R51.9 Headache, unspecified

Claim header

Patient account: PA-434130
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-014890 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-31: OPTIONS-PPO (PPO), effective 2024-10-01.
Timely filing	Pass		Received 24 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025099267 on file for 74177.
Provider network	Pass		In-network provider Desert Imaging Center (7235030955).
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: Desert Imaging Center2026-08-31 10:56
Established patient presents with encounter for screening mammogram for malignant neoplasm of breast; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

Prior auth letterPA2025099267_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-31 to 2026-11-29.
Itemized billitemized_PA-434130.pdf3 pages
Itemised statement totalling $2184.00 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-2026-025909	2026-08-31	Lakeside Imaging Center	$2,184.00	Needs review
CLM-2026-032638	2026-08-21	Northgate Cardiovascular Associates	$5,773.00	Denied

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